Gladys S. Felan
Alexandria
Summary
Professional Clinical leader with strong record of driving organizational success and fostering team collaboration. Adept at strategic planning, project management, and policy development. Known for flexibility in dynamic environments and results-driven mindset. Strong communication, problem-solving, and leadership skills that ensure consistent achievement of goals.
Overview
34
34
years of professional experience
1
1
Certification
Work History
Acting Deputy Director for Risk Assessment, Quality Assurance and Data Analytics Divisions/Director Clinical Operations for Internal Audit
Veterans' Health Administration (VHA)
Washington DC, DC, United States
09.2016 - 09.2025
- Coordinated and led the establishment of two high-level leadership panel members from VHA program offices, which included leading meetings with WMC, panel members, reviewing resumes, developing criteria, developing interview questions, and developing hiring tools for the selection of the Deputy Director for the IA position.
- Review and provide subject matter expertise on national policies impacting VHA and IA engagements.
- Foster relationships with other audit functions to include VA OIG, GAO, Health and Human Services (HHS), as well as VA, VHA, and VBA admins.
- Covers multiple leadership positions within the Office of Internal Audit, including Director of Clinical Operations and Acting Director for the divisions of Risk Assessment, Quality Assurance, and Data Analytics, in lieu of resources and performance management needs.
- Provide leadership advice in the resolution of internal disputes, and mitigate management issues by reassigning roles and responsibilities in collaboration with ADUSH in the Office of Risk and Ethics (ORE), Senior Leadership, and Human Resources.
- Lead with other Division Directors in the execution of an objective and systematic VHA Audit-Based Risk Assessment Program, encompassing all VHA clinical and nonclinical (administrative) components and programs.
- Actively participate with the Deputy Director and be responsible for ensuring contract deliverables in the execution of tasks, and serve as the second approving official for the performance of work.
- Co-lead overseeing the office's annual budget execution of $5.5 million and assisted in obtaining additional funding of $3.25 million to offset staffing vacancies for contractor support.
- Co-lead the internal audit capabilities maturity assessment to establish a baseline for program modeling and strategic planning efforts to support long- and short-term growth planning and development.
- Evaluates the timely execution of the VHA Internal Audit Portfolio of Programs: Audits, Advisory Services, Assurance, Assessments, and Evaluations, to ensure the achievement of the organization's mission set and Senior Leadership engagement requests.
- Directed cross-functional teams to achieve project objectives and align with corporate goals.
- Collaborated with stakeholders to define project scope, ensuring alignment with organizational strategy.
- Oversaw budget management, optimizing resource allocation to meet organizational needs effectively.
- Fostered a positive work environment by promoting collaboration, transparency, and open communication among team members.
- Developed strategic plans to achieve organizational goals, ensuring alignment with company''s mission and vision.
- Monitored performance metrics, analyzing trends to identify areas requiring attention or improvement.
- Oversaw project management efforts, ensuring timely completion of projects within allocated budgets and scope.
- Developed and implemented policies to streamline organizational processes and ensure compliance.
- Analyzed performance metrics to identify areas for improvement and drive data-informed decision-making.
- Mentored staff in best practices, fostering a culture of continuous learning and professional development.
Acting Deputy Chief Audit Executive/Director Clinical Operations for Internal Audit
Department of Veterans Affairs
Washington D.C.
09.2016 - 09.2025
- From January 2020 to January 2021, I served as the appointed Acting Deputy Chief Audit Executive (ADCAE). My responsibilities included, but were not limited to, assisting the Acting Chief Audit Executive (ACAE) as the advisor to the Under Secretary for Health on matters pertaining to the administration of the VHA Internal Audit and Risk Assessment (IARA) program. In addition to performing the full range of supervisory tasks, including but not limited to such duties as hiring, onboarding, writing position descriptions for series 0511 and 0610, assigning work to subordinate staff, training and coaching employees in job duties and program requirements, evaluating performance, preparing performance standards, and conducting mid-term and annual appraisals. I review recurring and non-recurring reports, policies, directives, and other official documents for the ACAE. I am considered a trusted advisor who provides value-added services and strategic advice to audit process owners, well beyond the effective and efficient execution of the VHA audit plan.
- Some highlighted achievements include:
- Leading Change: Championed alternative ways of IA engagement within Generally Accepted Government Auditing Standards (GAGAS) that provide VHA increased value and agility. Results:
- Advanced collaboration with internal audit communities of practice in VA OIG, GAO, Army Audit Agency, and Counsel of Inspectors General on Integrity and Efficiency (CIGIE) through Chief Audit Executives' research outreach.
- Developed and secured ARCC approval on two new collaborative methods in the 2Q FY20 ARCC meeting, with a clinical impact on women's breast cancer screening in Virginia and the community. This has resulted in policy changes that include improved communication and tracking of the BI-RADS 4 and 5 for further treatment of our veterans.
- Planned an agreed-upon procedure engagement (new engagement type) to validate MISSION Act Quality Metrics on VA's public-facing website to increase Veteran trust.
- Building Coalitions: Implemented a customer service improvement plan and metrics to deliver an improved customer experience through comprehensive Atlas and SIGMA contract consultation.
- Results:
- Collected and analyzed qualitative and quantitative data on four IA external customer groups. Developed action plans to improve the experience across external customer groups.
- Implemented at least one action with each external IA customer group, including establishing a baseline for measuring customer experience improvement.
- Lead two clinical audits this FY20, leveraging human capital resources by executing partnerships with the audit program officials and other stakeholders.
- Results Driven: Co-redesign the annual audit plan process to incorporate increased flexibility and agility, to more effectively pivot and focus on emerging risk areas requested by the ARCC.
- Partnered with ERM and CBI to increase the cohesiveness of risk management efforts across VHA program office components, which were previously conducted in silos, and to provide the first-ever collaborative VHA risk register and risk profile to VA ERM. Infused ARCC Risk Subcommittee and increased maturity level that five formerly siloed components (CFO, 10N, OCC, IAPO, 10E) were asked to participate in a cohesive VHA integrated risk discussion.
- Co-designed with the ACAE IA's audit planning strategy and process to increase IA's agility and responsiveness to emerging risks.
- Partnered with VHA senior leaders to propose 10 potential IA collaborative partnering efforts for FY21 to ARCC on their highest-ranked risk areas.
- Executed the FY20 Internal Audit Plan by delivering all IA products, and planning a 3rd collaborative new engagement.
- Business Acumen: Achieve IA FY20 Phased Hiring Plan to increase IA capacity. Results:
- Onboarded 5 of 7 authorized vacancies for IA in FY20 while CAE was on detail to another component.
- Collaborated in securing budget and hiring approval to continue IA capacity expansion for 12 additional hires in FY21. Postured for FY21 hiring success by progressing with WFM in the hiring process, up to the vacancy announcement for FY21 future hires.
- Developed a comprehensive plan to collect, analyze, and use customer experience data for IA's environment through contracted, anonymous interviews.
- Merged the new data with FY19's AES scores to create an IA Office Culture Improvement Action Plan.
- Led a virtual retreat to prioritize improvement actions.
- Implemented three IA customer service action plan improvement items in FY20, including the establishment of a baseline for measuring customer experience to improve service recovery and performance improvement.
- Created IA workgroups with designated leads to develop remaining IA customer service action plan improvement items in FY21.
- I developed a proposal and obtained approval for two clinical staff members to attend leadership courses as part of my succession planning for staff.
- I represented the Internal Audit Office and VHA at various meetings, both internally and externally.
- Oversaw financial management, ensuring fiscal responsibility and long-term sustainability for the organization.
- Worked closely with organizational leadership and board of directors to guide operational strategy.
- Advocated for legislative changes impacting veterans' rights, significantly influencing policy development at the local level.
- Led organization-wide training programs focused on best practices in veteran care and support services.
- Established partnerships with community organizations to expand outreach efforts and service delivery to veterans.
- Forge strong relationships with board members, providing regular updates on organizational progress and soliciting their expertise when needed.
- Monitored compliance with laws and regulations to protect organization from legal liabilities and penalties.
- Managed a diverse team of professionals, fostering a collaborative work environment for increased productivity.
- Fostered work culture of collaboration and inclusion to increase morale and reduce turnover.
- Built relationships with donors, government officials and other organizations to secure funding and support for organization.
- Promoted a culture of continuous improvement by encouraging professional development opportunities for staff members.
- Negotiated contracts with vendors, securing favorable terms while adhering to budgetary constraints.
- Represented organization to local public by giving presentations and speeches and participating in community events.
- Exercised appropriate cost control to meet budget restrictions and maximize profitability.
- Collaborated with external organizations including non-profits, businesses and government agencies to create mutually beneficial partnerships.
- Developed strategic partnerships with key stakeholders to expand the organization''s reach and influence.
- Drove strategic improvements to enhance operational and organizational efficiencies.
- Led successful fundraising campaigns, securing critical resources for program development and expansion.
- Advocated for organization and company mission to raise awareness and support.
- Strengthened internal communication channels to facilitate cross-functional collaboration and decisionmaking.
- Championed diversity, equity, and inclusion efforts within the organization to create a more inclusive work environment.
- Built and maintained strong company teams by hiring and training qualified staff to create positive and productive work environments.
- Aligned department vision, goals, and objectives with company strategy to achieve consistently high results.
- Increased organizational efficiency by streamlining processes and implementing new systems.
- Evaluated program outcomes using data-driven metrics, identifying areas for improvement and implementing targeted interventions.
- Optimized operational workflows, reducing overhead costs and maximizing resource allocation.
- Advocated for policy changes at both local and national levels to further support the organization''s goals and objectives.
- Set organizational goals and objectives to guide and direct company focus and achieve mission fulfillment.
- Developed and implemented organizational strategies to achieve set goals and objectives and secured long-term success.
- Implemented innovative marketing strategies to raise brand awareness and drive revenue growth.
- Created promotional materials and provided insightful information to social media, websites and print media to educate public.
- Spearheaded new program initiatives to address unmet community needs and advance the organization''s mission.
- Presented regularly at conferences or industry events showcasing the accomplishments of the organization.
- Negotiated beneficial agreements with service providers, enhancing operational efficiency and reducing expenses.
- Advanced organization's mission with launch of impactful community service programs.
- Led organization through significant transition period, maintaining stability and focus on strategic goals.
- Improved stakeholder relationships and trust by maintaining transparent communication channels.
- Facilitated successful accreditation processes, ensuring compliance with industry standards and regulations.
- Boosted team productivity and morale by developing comprehensive employee training and development program.
- Elevated event attendance and fundraising outcomes by organizing high-profile charity events.
- Spearheaded development and launch of user-friendly organizational website, increasing online engagement.
- Fostered culture of continuous improvement, introducing regular feedback mechanisms for staff and volunteers.
- Streamlined operations and reduced costs with implementation of efficient financial management systems.
- Implemented cutting-edge technologies to enhance data management and reporting capabilities.
- Drove significant growth in volunteer engagement by implementing targeted recruitment campaigns.
- Optimized resource allocation, conducting thorough needs assessments and prioritizing project funding.
- Negotiated with vendors to secure cost-effective deals for office supplies and equipment, managing budget effectively.
- Achieved notable increases in public awareness through innovative social media strategies.
- Maximized donor satisfaction and retention through personalized acknowledgment and engagement strategies.
- Secured substantial funding for new projects by cultivating relationships with key donors and stakeholders.
- Strengthened governance structures, establishing clear policies and procedures for board management and operations.
- Expanded organization's outreach, executing strategic partnerships with local and international NGOs.
- Enhanced organizational visibility and reputation by spearheading comprehensive rebranding initiatives.
- Managed financial, operational and human resources to optimize business performance.
- Represented organization at industry conferences and events.
- Established and maintained strong relationships with customers, vendors and strategic partners.
- Collaborated with legal, accounting and other professional teams to review and maintain compliance with regulations.
- Led recruitment and development of strategic alliances to maximize utilization of existing talent and capabilities.
- Developed innovative sales and marketing strategies to facilitate business expansion.
- Maintained P&L and shouldered corporate fiscal responsibility.
- Monitored key business risks and established risk management procedures.
- Initiated strategy to drive company growth and increase market share and profitability.
- Cultivated company-wide culture of innovation and collaboration.
- Devised and presented business plans and forecasts to board of directors.
- Created succession plans to provide continuity of operations during leadership transitions.
- Oversaw business-wide changes to modernize procedures and organization.
- Founded performance- and merit-based evaluation system to assess staff performance.
- Communicated business performance, forecasts and strategies to investors and shareholders.
- Analyzed industry trends and tracked competitor activities to inform decision making.
- Directed technological improvements, reducing waste and business bottlenecks.
- Formulated and executed strategic initiatives to improve product offerings.
Clinical Program Manager/Office of the Medical Inspector
Dept Veterans Affairs
Washington, DC
09.2005 - 09.2016
- Utilize expert and advanced clinical and administrative knowledge and experience to collect, analyze, and summarize policies, procedures, regulations, and federal laws to evaluate violations of standards of care and practice throughout the VHA.
- Respond to triage inquiries from veterans, medical center, and VISN's staff regarding the quality of VA health care. Lead clinical investigations and inspections requested by Veterans Service Organizations, Congress and congressional staff, the Secretary of Veterans Affairs, and the Under Secretary for Health (USH) in response to any quality-of-care issues posing the potential to affect our veteran population.
- Conduct and lead investigations on significant adverse and sentinel events, define their possible relationship to systemic deficiencies, and recommend needed changes in VHA executive staff and policy to address systemic concerns.
- Perform evaluations of the quality of care, quality assurance practices, programs, utilization of clinical resources, and other quality of care considerations.
- Communicate early warnings to the VHA Secretary, Under Secretary of Health (USH), DUSHOM, and other VHA and field executives about systemic issues identified during investigations or inspections that require immediate responses to protect the quality of patient care and the mission of the VHA.
- Analyze quantitative and qualitative data specific to the quality of care and practice, and conduct site visits to VAMCs and other programs paid for by the VA in order to discern trends and systematic issues that require guidance to improve patient care.
- Exercised effective communication, leadership, and relationships in VHA and the field offices by identifying clinical and administrative barriers, and recommending opportunities for improvement through clinical and administrative investigations to VHA executives.
- Assumed the role of the Associate Chief Officer for ADUSH Operations (10A5D). My contributions were significant in reviewing and revising correspondence that was processed for high officials, such as the Under Secretary for Health and, ultimately, the Secretary of the Department of Veterans Affairs.
- Other contributions included collaborating with leadership on issues and follow-up plans that are transcribed into reports, processing the graphic data for the FY 2010 VA Performance and Accountability Report (PAR), and other reports of highly confidential matters, which required me to work well beyond my scheduled work duties.
- Proficient in writing executive summaries, investigational reports, and responses, SOW for contracts, proposals, issue briefs, and other executive correspondence.
- I monitor and evaluate action plans that are submitted by medical centers as a result of recommendations made during and after an investigation.
- In 2006, GAO identified systemic problems in VHA's credentialing process. In 2008, I was tasked with this special credentialing and privileging audit project. I formed teams, developed protocols, provided training, and created an automated assessment instrument for a quality review of credentialing and privileging programs, involving a sample of over 5,000 health care providers at 8 VA Medical Centers nationally. I published an article based on the results of the study and received a commendation from the former Under Secretary of Health for the VHA.
- Co-lead an epidemiological study of infections associated with permanent pacemaker-like devices at Veterans' Hospitals. As a result, a white paper was published, and organizationally, changes within the surgery service program's policies were instituted, requiring the administration of appropriate IV antibiotics 1 hour prior to surgery as a protocol of care.
- In 2014, I began building the foundation for a new office of Internal Audit and Risk Assessment (OIARA) Capability within VHA, as directed by the Acting Secretary for Veterans Affairs, the Interim Acting Secretary, and OMI. Working with stakeholders across VHA and CBI, I developed a strategy on how OIARA can provide capabilities that span clinical, business, and operations to address VHA's highest priorities and systemic issues. The office became operational on October 1, 2016.
Chief, Quality Management
Dept Veterans Affairs
Decatur, GA, United States
10.2003 - 09.2005
- Managed the Medical Center's Quality Management program, employing 20 staff in Customer Service and Recovery, Risk Management, Patient Safety, Utilization Management, and Medical Staff Credentialing and Privileging Programs.
- Planned, managed, prioritized, and directed the duties of the Quality Management program staff in meeting the mission and vision of the VHA, VISN, and the Medical Center.
- As an active member of the Top Management team, I provided operating, management, and administrative officials with analyses and other evaluative materials essential to efficient planning, control, and direction of the Medical Center's health care delivery system.
- Directed quality improvement programs for RAI/MDS and NSQIP assessment tools.
- Developed and established a comprehensive program to review and evaluate activities required by VHA's Office of Quality Performance and by JCAHO, Health and Human Services, CARF, OIG, OMI, NCQA, URAC, and OSHA standards and regulations for hospitals and CBOCs.
- Created a mechanism to facilitate communications between clinical and administrative services for the discussion of their performance improvement initiatives and barriers within a top management forum for enhancing awareness, promoting accountability, and problem-solving.
- Implemented the Baldridge model throughout the Medical Center by reorganizing the Executive Committee's structure to serve as the basis for the alignment of counsels, designed to achieve organizational goals, and optimize performance.
- Revised policies and plans for achieving performance improvement priorities for FY 2003-2004 and participated in various Medical Center committees, where my expertise in VHA regulations and JCAHO standards was of value.
- Co-chaired the performance improvement committee, revised policy and practice to include enhanced multidisciplinary members charged with presenting on a scheduled basis, performance improvement plans, ongoing monitoring, and annual summaries.
- Instituted improvements in the EPRP process by establishing a second-level reviewer to review medical records identified by the abstractor as lacking elements that are not transparent to the reviewer or the EPRP liaison. This process improved our scores significantly, from 60% to 88%, and eventually, we achieved 98%.
- Revised performance measures for the clinical champions group responsible for attending the monthly VISN performance measures overview briefing with the VISN 7 Director, and VISN staff. The revised measures empowered the medical staff to obtain a better understanding of our EPRP efforts, and to establish more responsive action plans for improvement and deployment.
Quality Management Officer
Dept Veterans Affairs
San Francisco, CA, United States
03.2001 - 10.2003
- Managed the Medical Center's Quality Management program, supervising 40 employees in Customer Service, Risk Management, Utilization Management, Patient Safety Officer, NSQIP, and Medical Staff Credentialing and Privileging Programs.
- Planned, managed, prioritized, and directed the duties of the Quality Management program staff in meeting the mission and vision of the VHA, VISN, and the Medical Center. As a member of the top management team, I provided operating, management, and administrative officials with analyses and other evaluative materials essential to efficient planning, control, and direction of the Medical Center's health care delivery system.
- Developed a comprehensive program for all review and evaluation activities required by the Office of Quality Performance and by JCAHO, CARF, OIG, NCQA, URAC, and OSHA standards for hospitals and CBOCs.
- In collaboration with VISN 21 and the medical center's CSR&D program, we developed a self-assessment tool for the facilities to utilize in preparation for NCQA accreditation.
- Developed teams and field surveys, with ongoing follow-up and reporting of the status of recommendations and actions.
- Provided active leadership and guidance to interdisciplinary groups, including functional teams, committees, boards of investigation, root cause analyses (RCA), and healthcare failure mode and effect analysis (HFMEA) teams, with the objective of improving organizational performance. Lead the Medical Center's efforts to meet or exceed VHA, VISN, and facility-specific annual performance measures.
- Using EPRP data, I tracked and analyzed the Medical Center's performance on all measures. Participated at the VISN level to develop the network's Strategic Plan. Collaborated in updating the medical center's mission statement with the clinical planner for VISN 21 to comply with the congressionally mandated format.
- Hired 6 months away from a JCAHO survey, I contributed to the professional growth and development of my staff, colleagues, and other health care providers relative to my expertise in Quality Management by:
- A) Participating in the VISN 21 JCAHO Survey Readiness Workgroup:
- B) Bringing facility-specific information about JCAHO preparations to the VISN, and sharing successful preparation strategies with VISN 21 facility QM Coordinators.
- C) Summarizing and presenting survey-specific information and lessons learned to VISN facility representatives at the end of each survey day during the JCAHO survey.
- D) Assuming primary responsibility for the communications with VISN 21 Director (Robert Weibe, MD) and QM Officer (Judith Daley, RN) about all medical center QM activities, including the JCAHO accreditation survey, and compliance with national and VISN performance measures.
- E) Participating in the VISN 21 Quality Management Officers' workgroup.
- F) Shared specific lessons learned from Root Cause Analyses (RCAs) and Focused Reviews performed at the medical center with other VISN facilities.
Quality/Utilization Management Specialist
Dept Veterans Affairs
West Palm Beach, FL, United States
06.1996 - 03.2001
- Planned, developed, and deployed a Utilization Management program designed to maintain high quality patient care, while improving efficiency of hospital services in collaboration with the Chief of Staff Dr. John Vara.
- Designed processes and strategies for implementing the pre-certification program.
- Developed, designed, implemented, and evaluated regulations and policies for the Utilization Management Program. My knowledge of the Medical Center's structure, individual employees' capabilities, and departmental functions gave me the ability to identify and communicate difficult management issues and timely options and solutions.
- Recognized for communication skills, handled high-pressure situations in a professional and effective manner, and developed positive rapport with difficult providers.
- Developed and implemented CME related to the utilization of DRG/HICF regulations, InterQual, and Milliman and Robertson criteria, which decreased our bed days of care per 1,000 patients by half and currently lead the nation in this performance measure.
- Served as a consultant to process action teams and other VAMCs through VISN 8, and developed several policies related to the release of information, interfacility transfer, admissions, and discharges for the Miami VAMC through a joint collaboration with their Quality Management Department.
- Advised the Chief of Staff on the selection of appropriate monitoring tools, and the evaluation of cost-effective activities related to Utilization Management and Performance Improvement outcomes.
- Applied knowledge in performance improvement methodologies to facilitate systematic reviews, focused reviews, root cause analyses, medical reviews, administrative investigations, and patient satisfaction surveys.
- Chaired and facilitated various Process Action Teams in gathering, analyzing, and evaluating information/data concerning management processes, drawing conclusions, and recommending appropriate action in clear and concise reports.
- Planned and coordinated programs for all nursing personnel on all tours of duty, designed to extend basic education and QM performance improvement.
- I chaired the Nursing Service Quality Management Committee and served as a member of the SRMVC Quality Management Committee.
- Developed and provided JCAHO survey preparations.
- Developed schedules for the surveys, and coordinated survey activities through the medical center, that resulted in obtaining accreditation with commendation for the service.
- Evaluated cost-effectiveness and cost containment in the achievement of the QM program goals as a basis for planning the budget for the fiscal year.
- Coordinated clinical investigations, and submitted substantive reports and recommendations to the director.
- Acted as a quality consultant to other services in the development of their performance improvement activities and plans.
- Appointed by the COS as the COTR for four contracted CBOCs, Collaborated in the development of the SOW and provided compliance oversight.Wrote monthly status updates with findings, conclusions, and recommendations for improvements, and reported to leadership..
Nurse Administrator, NHCU
Dept Veterans Affairs
West Palm Beach, FL, United States
02.1994 - 06.1996
- Activated a 120-bed nursing home care unit. Recruited, selected, and managed a large number of professional nurses and ancillary staff: 30 RNs, 10 LPNs, and 60 NAs.
- Developed and implemented orientation programs for nursing staff, medical staff, and ancillary services.
- Developed and implemented standards of care and practice specific to individual competency and qualifications.
- Initiated the Clinical Preceptorship and Specialty Rotation Program according to VISN directives for students and staff.
- Developed job descriptions for all nursing and ancillary staff.
- Developed collaboratively with the IMS staff, many templates for nursing documentation became part of the first computerized medical record in the facility.
- Collaborated in the development of the computerized management of information for the medical center.
- Participated in Medical Board Committees on Medical Standards, Infection Control, and Disaster Planning, as well as various hospital project management teams and task forces.
- Designed and conducted management surveys, audits, research projects (Medication Errors in a Tertiary Hospital), and studies (e.g. Appropriateness in the utilization of hyperbaric treatment for osteoradionecrosis. The hyperbaric study was used in contracting this service, which generated extra revenue.
- Provided advisory services on a wide variety of substantive issues.
- Developed and implemented Risk Management and Performance Improvement Plans for Nursing Services during the activation phase.
- Planned, programmed, and executed the appropriated budget for the NHCU.
- Led interdisciplinary teams in developing policies that align with regulatory standards.
- Streamlined workflow processes, reducing patient wait times through effective resource management.
Quality Management Coordinator/Instructor
Dept Veterans Affairs
Bonham, TX, United States
07.1991 - 02.1994
- Assumed dual role responsibility for the assessment, planning, implementation, and evaluation of the Nursing Service Quality Management Program and Education Program.
- Developed the philosophy of the QM and education program in accordance with the mission and vision of the medical center.
- Collaborated in the development of the Medical Center's Strategic Plan by developing and deploying Performance Improvement activities directed toward measuring patient care safety, utilization review, credentialing and privileging, and meeting specific performance measures.
- Instrumental in coordinating and leading all activities associated with obtaining hospital accreditation status.
- Developed new employee training modules, and tracked all hospital employee compliance with the mandatory reviews.
- Lead all patient safety initiatives and developed indicators, as appropriate, to measure milestones.
- Developed charters and provided "just-in-time training" for ad-hoc groups designed to improve a process or system, with metrics to track outcomes.
Education
Technical or Occupational Certificate - Healthcare Auditing
Association of Healthcare Internal Auditors
Denver, CO, United States09.2017
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John Hopkins Carey Business School
01.2020
Technical or Occupational Certificate - HealthCare Administration
Health Care Leadership Institute for Executive Carrier FieldEmployees
Washington, DC, United States02.2009
Technical or Occupational Certificate - Utilization Management
National Certified Professional in Utilization Management
West Palm Beach, FL, United States07.2002
Master's Degree - Administration, Care of the Adult and Geriatric Patient
University of Puerto Rico, Medical Science Campus
05.1991
Bachelor's Degree - Nursing
InterAmerican University of Puerto Rico
San Juan, PR, United States06.1978
Skills
- Effective strategic planning
- Organizational change management
- Project oversight and execution
- Strong relationship-building abilities
- Effective time management
- Skilled in Microsoft applications
Affiliations
- Institute of Internal Auditors (IIA)
- American Nurses Association
- American Organization for Nursing Leadership
- Association Healthcare Internal Auditors (AHIA)-National
- Association for HealthCare Quality
- Administration Nurses Association
- American College of Healthcare Executives
- Puerto Rico Board of Nursing – Member
- Florida Board of Nursing – Member
- Virginia Board of Nursing-Member
Certification
- Puerto Rico RN License #012444
- Florida RN License #9346967
- Virginia Multistate License # 1335685
Languages
Spanish
Native or Bilingual
Professional Publications
- Chester I Davis, MPH, SCD, John R. Pierce, MD William Henderson, PhD, Gladys S. Felan RN, MSN, CPUR et al. Assessment of the Reliability of Data Collected for the Department of Veterans Affairs National Surgical Quality Improvement Program. Journal of the American College Of Surgeons; Vol. 204, No. 4, 2007
- White Paper Report No. 2008-D-1228. December 30, 2008, Credentialing at Selected Department of Veterans Affairs Medical Centers; Veterans Health Administration, Washington, DC.
Timeline
Acting Deputy Director for Risk Assessment, Quality Assurance and Data Analytics Divisions/Director Clinical Operations for Internal Audit
Veterans' Health Administration (VHA)
09.2016 - 09.2025
Acting Deputy Chief Audit Executive/Director Clinical Operations for Internal Audit
Department of Veterans Affairs
09.2016 - 09.2025
Clinical Program Manager/Office of the Medical Inspector
Dept Veterans Affairs
09.2005 - 09.2016
Chief, Quality Management
Dept Veterans Affairs
10.2003 - 09.2005
Quality Management Officer
Dept Veterans Affairs
03.2001 - 10.2003
Quality/Utilization Management Specialist
Dept Veterans Affairs
06.1996 - 03.2001
Nurse Administrator, NHCU
Dept Veterans Affairs
02.1994 - 06.1996
Quality Management Coordinator/Instructor
Dept Veterans Affairs
07.1991 - 02.1994
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John Hopkins Carey Business School
Technical or Occupational Certificate - HealthCare Administration
Health Care Leadership Institute for Executive Carrier FieldEmployees
Technical or Occupational Certificate - Utilization Management
National Certified Professional in Utilization Management
Master's Degree - Administration, Care of the Adult and Geriatric Patient
University of Puerto Rico, Medical Science Campus
Bachelor's Degree - Nursing
InterAmerican University of Puerto Rico
Technical or Occupational Certificate - Healthcare Auditing
Association of Healthcare Internal Auditors