1. Amanda Schefter RN MHA CPHQ
400 Hickoryhill Drive
Encinitas, CA 92024
Home: 760-632-1881 Cell: 760-518-3728 Email: aschaftel@yahoo.com
OBJECTIVE
A position inPerformanceImprovement/Survey Readiness utilizingmyabilitiesin teamfacilitation,
excellentcommunication skills,andsurvey readinessprocesses, conductingmocktracers and motivating
adherence toregulatoryrequirements.
EXPERIENCE
VETERAN’S ADMINISTRATION SAN DIEGO HEALTHCARE SYSTEM
Accreditation/PIConsultant
(12/29/2014-present)
Responsible for ongoingsurveyreadinessactivities forThe JointCommission(TJC), Commissionon
Accreditationof RehabilitationFacilities(CARF),Office of InspectorGeneral(OIG), LongTermCare
Institute (LTCI).Facilitate performance improvementteams,rootcause analysisteams, assistin
developmentof actionplanspostsurveyandmonitoringcompliance. Revise mocktracertoolstoreflect
the most recentregulatorystandardsandorganizational policies andprocedures. Responsiblefor
preparingservice DirectorandCEOfor the QualityCouncil meetings. Provide coaching andassistance to
servicesforreportingandfollow uptothe QualityCouncil.Provide GoverningBoardreportsonthe
QualityCouncil accomplishments andbarriers. Update TJCFocusedStandardsAssessmentTool with
standardupdatesandobtaininputfromservicestomeetcompliance. Serve asorganizational experton
standardinterpretationandprovideguidance anddirectionasneeded.Provide expertise forupdating
service relatedandorganizational policies andproceduresbasedonregulations,governmental
handbooks/directivesand existingVeteran’sAdministrationSan Diego(VASDHS) policiesand
procedures.Throughongoingmocktraceractivitiesandroundsprovides“real time”trainingand
directionforstaff;while providing informationto organizational Leadership ongaps inexisting
processes,whichare addressed atthe time of findings.
 PassedTHJ Surveyin2016 withfull accreditationstatus.Actionplansaccepted.
 Spinal CordInjury Unitreceived full CARFaccreditationin2018 withminimal documentation
relatedfindings
 Behavioral HealthoutpatientCOREprogramreceivedfull CARFaccreditationin2019 withone
minorfinding
 Revisedthe VASDHSHearingConservationProgramwithimprovedscoresforcompletedhearing
tests(initial hireandannually)

2.  Improved Nursingadministrationerrorsof missedmedicationsfrom16% to 11%
 Revisedmedicationadministration processtoeliminate the independentdouble checking of
subcutaneous insulin andheparin basedoncommunitystandardandevidencebasedliterature.
95% reductioninthe numberof independentdoublechecks neededby Nursingstaff.
 Facilitatedthe VASDHSPainCouncil onrevisingthe inpatientNursingAssessmentNote
Template tomeetTJCrevisedPainStandardseffective January2018
KINDRED HOSPITAL SAN DIEGO
Director of Quality Management
(11/13/2006-12/2014)
Responsible fororganizational performanceimprovementstrategiesandimplementationof program.
FacilitatesSanDiegoRiskManagementprogram.ServesasPatientSafetyOfficer.Oversee
implementationof National PatientSafetyGoals.ResponsibleforJointCommissionSurveyReadiness
Program andoverseescompletionof FocusedStandardsAssessment. PerformsRCAs,FMEAs,andPI
teams. Facilitate Medical Staff PeerReview. FacilitateCDPH/CMSinvestigationsandcomplete action
plans.Track incidentreports andimplementaction plans.Intervene withfocusfamiliesandtrackand
trendpatientcomplaints.ServeonSouthernCaliforniaCMS/JointCommissionSurveyTeam.Provide
educationasneeded.
UNIVERSITYof CALIFORNIA SANDIEGO
Manager of Performance Improvementand PatientSafety
4/20/04-11/3/06
Manager of Performance ImprovementandPatientSafety
Assistsinthe implementation of the National PatientSafetyGoals,Medical Staff PeerReview,
facilitationof performance improvementteams(includingFMEAs). Performrootcause analyses,
monitorincidentreports andfollow through,andmaintainoversightof the JointCommissionHeart
Failure Core Measure.Developpoliciesasneeded.Participate innew employee orientation.Developed
tracer teamquestionsandleadstracerteam. Assiststhe organizationinmaintainingcontinualsurvey
readiness.
SHARP REES-STEALY
Manager of Quality Improvement
9/18/2000-4/4/2004
Responsible forsystemwideQualityImprovementactivities,LIPcredentialing,coordinationof patient
complaints,and responsibleforRiskManagementProgram.Responsible forfacilityaudits,HealthPlan
surveys,andcoordinationof NCQA requirements.Responsible forHEDISdata collectionforhealthplans.

3. TRI-CITY MEDICAL CENTER
Director of Quality and Risk Management
October 1996-September2000
1995-1996 Quality and Risk Management Supervisor
Additional Positionsavailable onrequest.
EDUCATION
Advanced Transformational Coaching Certification 8/2017
CertifiedLeanGreenBelttrained (certificationnotreceiveddue to vendor transition) 3/2017
CertifiedLeanYellowBelt 12/2016
CertifiedJointCommission Professional (CJCP) 1/31/2015
CertifiedProfessional inHealthCare Quality(CPHQ) 3/8/2013
Master’s inHealth Care Administration,CaliforniaCoast University,Santa Ana, CA 1998
Equivalent to BSN (courseworkin preparation for MSNprogram) 1988
Bachelor’s inHealth Science,Chapman College,SanDiego,CA 1984
AS/RN Palm Beach State College,Florida