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Quality & Patient Safety Improvement
Staff
John Gillean, M.D., M.B.A.
Senior Vice-President, Physician Integration Services
Dr. Gillean was appointed senior vice president and chief medical officer of CHRISTUS Health in July 1999, after serving in that role in an interim capacity from the inception of CHRISTUS in February 1999. In this role he is responsible for the physician employment/practice management model; physician/clinical integration; coordination of the council approach in the clinical disciplines and cross-linking those functions; quality management and patient safety; development and management of a system-wide model to share best practices; developing processes/systems to assist providers with care management; accreditation readiness and oversight to include system approach to a Baldrige National Quality Program and nursing Magnet designation; physician professional development, including leadership development, continuing medical education and GME; and clinical standard research and development, as well as clinical reengineering.
Dr. Gillean served as vice president, physician integration in 1998 for the Sisters of Charity Health Care System (SCH), one of the two systems acquired in the formation of CHRISTUS Health. Prior to that, beginning in 1995, he had served as medical director for a local SCH market overseeing the MSO, PHO and serving as a regional medical director for Arkansas Blue Cross Blue Shield. Dr. Gillean was in the private practice of internal medicine from 1980 to 1995.
Dr. Gillean received his medical degree from the University of Arkansas for Medical Sciences in 1977. After completing an internal medicine internship at Tulane University in 1978, he completed his internal medicine residency in 1980 at University of Arkansas for Medical Sciences and became board certified in 1981. Dr. Gillean also received a M.S.H.A; from University of Colorado, Denver in 1996.
Dr. Gillean is a member of the American Medical Association, the Texas Medical Association, the American College of Physician Executives, and the American College of Physicians. He has served on the boards of numerous local and state charitable organizations.
Benton Baker III, M.D., M.S.
System Medical Director, Vice President/Chief Medical Officer for CHRISTUS Medical Group
Benton Baker III, M.D., MSc, is system medical director for professional development. In that role he is responsible for the development, implementation and administration of physician educational activities, which encompass business literacy, service excellence, clinical improvement and compliance issues. This responsibility is directed primarily to CHRISTUS Health physicians whether they are employed full or part time or private practitioner members of CHRISTUS Health medical staffs. He also serves as Chairperson of the Physician Advisory Council, scheduling, developing the agenda and conducting its monthly meetings. He works closely with the Quality Improvement and Patient Safety Improvement staff which allows for the ongoing dissemination of quality and patient safety information to CHRISTUS Health physicians. Additional responsibilities include serving as the Physician Leader of the CHRISTUS Health Internal Survey Assessment Team (ISAT) as well as chief medical officer of CHRISTUS Medical Group.
Dr. Baker earned his M.D. at Baylor College of Medicine in Houston and received his Master of Science in Medical Management from the University of Texas-Dallas School of Business. He is a Board Certified Obstetrician and Gynecologist who has been with CHRISTUS Health (formerly the Sisters of Charity Healthcare System) since 1993 when he became the academic chief and residency director of the Obstetrics and Gynecology residency at CHRISTUS St. Joseph Hospital. While at CHRISTUS St. Joseph, he also served as the director of Graduate Medical Education. Additionally, he has served as professor of Obstetrics and Gynecology at the University of Texas Medical School Houston, University of Texas Medical Branch Galveston and the University of Massachusetts. He was an oral examiner for the American Board of Obstetrics and Gynecology and has authored or coauthored more than 25 peer reviewed articles and books.
Terry Siebert, M.D.
Regional Medical Director, CHRISTUS Health Southeast Texas
Dr. Siebert mentors physician groups in CHRISTUS’ Southeast Texas region to support service quality, outcomes and clinical improvement processes. He assists in the development of case management infrastructure for clinical improvement, reengineering care and managing practice variation and collaborates with physicians in developing a consistent approach to measuring provider and patient satisfaction. Dr. Siebert assists leadership in developing systems and services that integrate care and outcomes across the region. He works with PHO, MSO and IPAs to develop techniques to manage risk contracts including: demand management, episodic care management, disease management and pharmacy management. He develops and continuously improves a system for rapid, effective provider communication including market- and regional-based physician leadership meetings.
Dr. Siebert received his bachelor’s degree from Baylor University in Biology and his M.D. from Baylor College of Medicine in Houston. He is Board Certified in Internal Medicine and Infectious Diseases.
Eileen Sampanes, M.B.A., R.N.
System Director, Clinical Excellence & Patient Safety Officer
Quality and Patient Safety Improvement (QPSI)
With responsibility for clinical redesign, Eileen directs the QPSI team that manages clinical redesign initiatives, data mining and research for clinical indicator outcomes and comparatives, clinical reporting for the Balanced Scorecard, CORE measures and a variety of custom reports with comparatives from national databases. QPSI serves as a clinical and clinical operations resource for all regions and other system-level departments. Clinical programs developed include complementary and alternative medicine business planning, a case management program and the CHRISTUS Palliative Care program. QPSI also developed and manages the CHRISTUS Best Practice program (an internal review team to conduct JCAHO mock surveys), and led the efforts for the development of the CHRISTUS Service Guarantee. In addition to these ongoing activities, as a 2006 Baldrige Examiner, Eileen is leading the preparation of a submission for the Baldrige Award by mid-2008.
Eileen and her staff of health care professionals provide the management for the clinical councils including the Chief Nurse Executive Council, Quality Director Council, Case Management Council, Infection Control Professional Council, JCAHO Coordinator Council and the Patient Safety Council. She is also responsible for the development of clinical standards of care using evidence-based medicine and the corporate maintenance of these clinical standards in the electronic medical record as it is developed.
Ms. Sampanes has previously acted as director of a managed care company, a demand management call center and as a director of medical services for a start-up HMO. She has been a principal in a consulting firm specializing in IPA, PHO join ventures and managed care consulting for strategic planning, network development and contracting, operations, utilization management (UM) and quality management (QM) program development and implementation. As an instructor for the University of Phoenix, she taught Business Research, Management, Health Care Marketing, Health Care Economics, Health Care Finance, Communication and Organizational Development. Her early nursing career was as a Clinical R.N. for ICU/CCU units.
Her educational background includes R.N. preparation at Grand Rapids Community College, a B.S.B.A. from Aquinas College and an M.B.A. from Arizona State University.
Amir Khan, B.S.
Database Analyst and Administrator
Amir provides technical leadership in study and project design as well as in-house consultation throughout CHRISTUS Health. He assists with the generation of reports for Clinical/Outcomes research, automates and oversees processes for quality management activity by health care center and system, and supports clinical quality outcomes studies with applications and development of programs. He has designed and developed the Performance Measurement System, a Revenue Cycle Management system, a Funds Management System, a Managed Care Contracts system, and a Utilization Review Audit Database. Mr. Khan also develops programs and training for the Physician Integration team.
Amir is proficient in SQL Server (Client Server technology), works extensively with VBA, Visual Basic, MS Access and Power Builder.
Mr. Khan received his bachelor’s degree in Computer Science from the University of Kansas.
Brian Moses, B.A.
Senior Specialist – Financial/Decision Support
Brian provides support through the analysis of financial information and financial modeling. This includes coordinating the implementation process for an enterprise-wide system, report generation and training and technical support for end users. Brian assists in the data standardization process to facilitate comparative reporting and uses the financial information for establishing financial impact, predicting future income and cost, as well as comparing actual expected cost and income. He acts as a liaison between Information Management, Quality and Patient Safety Improvement staff, vendors and external customers. Mr. Moses provides financial analysis and expertise to QPSI, Corporate projects, and Senior Leadership of CHRISTUS Health as well as participating in the budget preparation and tracking process for QPSI, HealthPrompt, and other Physician Integration divisions. Brian assists in the development, coordination and support of special projects supported by the QPSI team, supports strategic initiatives, creates financial models for management of medically-related resources and alternative financial models to support contract negotiations, including risk pool management. He analyzes managed care contacts for financial support and operational impact on HCCs and CHRISTUS Health along with review of existing managed care contracts for reimbursement, stop-loss and risk elements to compare to actual performance benchmarks. He reviews existing contracts for contract reimbursement optimization and participates in the contract negotiation team by providing financial expertise, assistance with market analysis and business planning. Mr. Moses assists in the data standardization process – GL, Cost Accounting process and decision support data element standardization.
Brian received his bachelor’s degree at University of Sioux Falls.
Catherine A. Mullins, R.Ph., M.S.
Director, Clinical Informatics and Patient Safety
As Director of Care Management Informatics, Catherine directs and coordinates clinical redesign projects, database development for clinical redesign projects, oversight responsibility for Performance Measurement System (Dashboard Application), supports the Patient Safety Initiative and is the liaison to Pharmacy Resource Group. Catherine and her staff are responsible for managing changes to clinical content in the Meditech Clinical Modules.
In Ms. Mullins’ prior experience as the manager of Clinical Pharmacy Services at CHRISTUS St. Joseph in Houston, she implemented Unit Based Pharmacists, multiple pharmacist initiated therapeutic interchange and dose reduction protocols. She was the CHRISTUS Health Southeast Texas Region/Gulf Coast Region HBOC Pharmacy Coordinator/Resource, oversaw the multiple HBOC/McKesson system implementations across the system and was Team Leader/Facilitator for multiple PI projects at department and facility levels.
Catherine’s strengths include database design/development to support clinical research projects, analysis skills of data from clinical research projects, clinical research skills of evidence-based medicine and over 20 years of pharmacy practice experience as clinician and manager.
She earned her bachelor’s degree in Pharmacy at the University of Texas at Austin and her master’s in Pharmacy at the University of Houston.
Dawn Kirkland, R.N.
Manager, Clinical Standards Administration
The Manager of Clinical Standards Administration analyzes, supports and maintains clinical documentation standards for use in patient health information management. Dawn conducts analysis of system requirements, operational needs and their impact on clinical operations, as well as updating clinical dictionaries as required over time to support clinical documentation, reporting and quality indicators and implementation costs for existing system applications and new technology-based automated solutions. She researches, develops, defines and coordinates testing and implementation for new or enhanced technology for evidence-based solutions to optimize the use of electronic medical records. Mrs. Kirkland assists and participates in the design and roll-out of the electronic medical health information management system and other system resources, with emphasis on how such design and roll-out affects the delivery of health care for all associated providers. She analyzes process and procedures and recommends process improvements to streamline and standardize automated administration. In conjunction with Information Management, Dawn provides direct support to the system on implementation of clinical redesign processes as they relate to the information systems and provides clearinghouse services for requests for changes to the health record and other clinical systems. She coordinates with regional clinical and Information Management sources to maintain consistent delivery of system tables, matrixes, databases and interfaces to other systems or service providers. Mrs. Kirkland provides systems analysis on problem resolutions with all clinical specialties, system vendors and IM personnel.
Dawn has spent her nursing career taking care of ICU patients. In 2005, she became the Nursing Information Specialist for CHRISTUS St. Catherine Hospital in Katy, Texas. During the year-and-a-half in this position, her main focus was the Unity Project, CHRISTUS’ main effort to systematize and blend information and clinical data, processes and technology. She was involved in the Standards build for PCS (clinical documentation) and then assumed the position of CHRISTUS Health Gulf Coast Region Core Team Leader for the Emergency Room Management Module before joining QPSI as the Manager of Clinical Standards Administration.
Dawn received her associate’s degree in Nursing from Del Mar College.
Jean Dols, Ph.D., R.N., CNAA-BC, CHE
Director, Quality for Clinical Standards of Care
The Director of Quality for Clinical Standards provides research and evaluation for evidence-based guidelines and protocols to support clinical quality improvement and patient safety initiatives with demonstrated improved clinical outcomes. Dr. Dols provides research education and operational expertise to facilitate effective and timely implementation of clinical guidelines and protocols. She facilitates the Chief Nurse Executive Council and supports the design and implementation of projects and programs that improve nursing practice and the quality of patient care services.
Dr. Dols received a bachelor’s degree in science from the College of St. Teresa in Winona/Rochester, Minnesota and a master’s degree in science and Doctorate from Texas Woman’s University in Houston. She is Board Certified in Nursing Administration, Advanced and is a Board Certified Healthcare Executive. A Health care Administrator with more than 20 years of varied and increasingly responsible leadership positions in Nursing, Strategic Planning, Information Technology, Development, Research, Outsourced Services and Patient/Staff Education, Dr. Dols has strengths in communication, organization, program management and business development.
Nicky Scott, MS, R.N., CPHQ
Director, Quality for Accreditation
The Director of Quality for Accreditation serves as the corporate representative to the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and is responsible for the design, development, implementation and evaluation of quality improvement processes for accreditation, as well as internal and external readiness assessments for JCAHO and other accrediting agencies across the continuum of care offered by CHRISTUS Health. Nicky provides expertise, education and leadership for health care center administrative leaders,nursing and quality management personnel and staff physicians for preparation and updates of regulatory and accreditation agency requirements as they occur. Nicky developed the Survey Readiness Oversight program and is the team leader of the CHRISTUS Health Internal Survey Assessment Team (ISAT) and is responsible for the development, education and coordination of activities for ISAT. She is the CHRISTUS Health Sponsor Coordinator for the Maryland Hospital Association/QI Project that coordinates reporting activity for CORE Measure data submission. Nicky developed the CHRISTUS Health Best Practice program and manages the process through education of Associates, the collection and review of Best Practice submissions as well as distribution to qualified peer reviewers and final review by the Senior Leadership Team.
Ms. Scott brings over 30 years of experience in the health care field that includes clinical specialization in OR, business and ambulatory/outpatient clinic management, 15+ years in quality management and accreditation (NCQA, JCAHO, HCFA now CMS) processes and 10+ years of health care risk management.
She graduated from Charing Cross School of Nursing with a diploma in Nursing, St. Peter's Hospital with a Joint Board of Clinical Nurse Specialist (OR) and the Regents College Albany with an Associate of Science Nursing degree (all located in England), LeTourneau University with a bachelor’s of science in Business Management and Finch University/The Chicago Medical School with a master’s of science in Healthcare Risk Management.
Reggie Allen, R.N.
Director, Clinical/Resource Management
As Director of Clinical/Resource Management, Reggie performs organization-wide assessments of processes and systems in place to merge and manage the clinical and financial outcomes of the admitting-discharge process. He develops plans for redesigning systems and processes to improve clinical outcomes and financial performance. As former chief operating officer and chief nurse officer, Mr. Allen participated in operations restructuring and enhancement of Patient Care Delivery Models, merging quality management and resource management functions. He has held roles as a director of Nursing, patient care coordinator, nurse manager and an independent nurse consultant. Reggie was recognized by the 1998 Medical Quality Management Sourcebook for an approach to patient care management and quality monitoring process and Who’s Who in Nursing. He has an extensive background and training in strategic quality planning, performance improvement, leadership development, clinical/resource management, and revenue cycle management.
Mr. Allen received his B.S.N. from Vanderbilt University.
Sharon Boyce, B.S.
Project/Office Manager
The Project/Office Manager is responsible for general department requirements, supervision and coordination of administrative staff, providing training and assistance to all QPSI staff when needed, and determination of the best use of resources for the department. Sharon enhances work methodologies and tools in project management by offering assistance to team leaders in project research, education and development and timely quality reporting. In addition, Ms. Boyce helps with logistical details of events or special projects and facilitates educational credit requirements as required. She acts as a liaison to Human Resources regarding applicants, new hires and department Associates and oversees the organization of office functions and communication files, including contract management and presentations. Ms. Boyce uses her graphic design and marketing education for department presentations and other printed media. She designs, coordinates, implements and maintains changes and additions to intranet, internet and Share Point websites. Sharon also assists with the development and coordination of team-sponsored conferences and educational programs as well as assisting with educational CME and CEU credits.
Sharon received her bachelor’s degree in marketing from Trinity College/University and a bachelor’s from Clayton College of Natural Science.
Susan R. Huang-Tan, M.S., B.S.
Data Mining Specialist
Ms. Tan works with database management, maintaining and establishing database dictionaries and standards, statistical analysis and modeling, financial and clinical studies, running reports, supporting users and training and developing applications for the system. Her major responsibilities in data mining include looking for clinical patterns and variations, generating reports for Clinical/Outcomes research, providing statistical analysis and modeling expertise and application and development for clinical quality outcomes studies. She has partnered in the development and implementation of the performance measurement database and the quality assurance of performance measurement database, has developed a school-based health center database, uses the Solucient database to calculate each DRG’s expected data and the goal for each hospital and has prepared ad-hoc reports for the corporate office and CHRISTUS hospitals using the system dashboard and Solucient databases.
Susan received her bachelor’s degree from Xiamen University in Xiamen, China and master’s in information system and decision science from Louisiana State University.
