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Pioneers in Quality Advisory Panel Members

PIONEERS IN QUALITYTM

T H E J O I N T C O M M I S S I O N

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David W. Baker, MD, MPH, FACP Executive Vice President, Health Care Quality Evaluation

The Joint Commission

David W. Baker, MD, MPH, FACP is the Executive Vice President for Health Care Quality Evaluation at The Joint Commission in Oakbrook Terrace, Illinois. A member of the senior management team, he heads the Division of Health Care Quality Evaluation, which subsumes The Joint Commission’s activities associated with the development, testing and implementation of evidence-based standards, survey methods, national patient safety goals, and performance

measures across all of The Joint Commission’s various accreditation and certification programs. Dr. Baker has administrative responsibility for The Joint Commission Departments of Quality Measurement, Health Services Research, and Standards and Survey Methods.

Before assuming his current position, Dr. Baker served since 2002 as Chief of the Division of General Internal Medicine and Geriatrics at the Feinberg School of Medicine at Northwestern University, and Deputy Director, Institute for Public Health and Medicine at that school. In this capacity, he oversaw the largest division of the Department of Medicine, including clinical practices, residents’ continuity of care clinics, and research programs. He established the hospital medicine program at Northwestern Memorial Hospital, which eventually became the first fully independent Division of Hospital Medicine in a major academic medical center. He also created and directed Northwestern’s first practice-based research network, including affiliated community primary care

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practices and federally-qualified health centers. In addition, Dr. Baker has maintained his own very active research portfolio and has been a major contributor to the ongoing national quality measurement discourse. He chairs the American College of Physician’s Performance Measurement Committee and serves as its representative to the Measures Application Partnership Coordinating Committee. He has also served as a member of the Measure Implementation and Evaluation Committee of the Physician Consortium for Performance Improvement.

Prior to joining Northwestern, Dr. Baker held the position of Associate Professor of Medicine and Epidemiology-Biostatistics at Metro-Health Medical Center and Case Western Reserve University in Cleveland. In that role, he developed a very successful health services research program, including studies of health literacy, health outcomes for the uninsured, and evaluation of Northeast Ohio’s hospital report card program. He also led Metro-Health’s heart failure disease management program. Earlier, he worked at the Grady Memorial Hospital, was an Assistant Professor of Medicine at Emory University School of Medicine, and an Assistant Professor of Medicine at the Harbor-UCLA Medical Center at the UCLA School of Medicine while working at the Harbor-UCLA Medical Center.

Dr. Baker received a Bachelor’s Degree from the University of California and a Doctor of Medicine from the UCLA School of Medicine. He also has a Master’s Degree in Public Health from the UCLA School of Public Health. He is a fellow of the American College of Physicians, having completed a residency in internal medicine at Harbor-UCLA Medical Center and a research fellowship with the RWJ Clinical Scholars Program at UCLA. He has served on numerous professional Boards and Committees, including NIH study sections, has authored more than 200 peer-reviewed publications, and is a frequent speaker at a wide variety of research and policy meetings.

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Jennifer BeschDirector, Population HealthCerner Corporation

As the Director of Quality Reporting Submissions, Jennifer has executive responsibility for the submission of data related to regulatory and quality measure reporting programs. She has experience working with multiple national programs and facilitates Cerner relationships with leadership representing the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission.

Jennifer joined Cerner in 1999 in a consulting role. In 2005, she was

a founding member of the innovative new Bedrock team focused on streamlining the electronic health record (EHR) design and implementation process. In 2009, Jennifer was promoted to lead a team of solution designers responsible for application design.

In 2011, Jennifer launched the Quality Reporting Operations team. Her team has responsibility to connect clients to the Cerner Quality Clearinghouse for access to executive level dashboards featuring quality and meaningful use data. Since then, her team has grown in scope and responsibility including ownership of the relationship and submission of quality data for regulatory programs.

Jennifer is a graduate of University of Kansas and has a Bachelor of Science in Business Administration. She also holds a Master of Business Administration from Baker University

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Zahid Butt, MD, FACGChief Executive OfficerMedisolv, Inc.

Dr. Zahid Butt is a board certified Gastroenterologist and the former Director of Clinical Informatics at St. Agnes Healthcare, a member of Ascension Health. He has served on several Health IT task forces both in government and the private sector. He currently chairs the Healthcare Information and Managment Systems (HIMSS) Performance Measurement Taskforce and is Co-Chair of the National Quality Forum (NQF) / Office of the National Coordinator for Health

Information Technology (ONC) sponsored Value Set Harmonization Committee. As a nationally recognized expert in quality measurement, he has served on several Centers for Medicare & Medicaid Services (CMS) Technical Expert Panels (TEP) charged with development and maintenance of Quality eMeasures for future quality reporting programs. Over the last 30 years, he has held a variety of leadership positions in diverse healthcare settings and provides key insights into leveraging Health IT to improve quality of care. In addition to quality measurement and reporting, his areas of expertise include healthcare data analytics and clinical decision support.

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Jayne Hart Chambers, MBASenior Vice President Quality

Federation of American Hospitals

Jayne Hart Chambers is Senior Vice President for Quality at the Federation of American Hospitals. Chambers is a respected analyst of health care quality measurement and design. She focuses her efforts at the FAH on reaching consensus among diverse stakeholders and the federal government to ensure hospitals have the best tools available to provide safe and effective patient care. In this arena, Chambers focuses on appropriate payment for the provision of the highest quality patient care.

Chambers is responsible for analyzing strategic public policy issues affecting hospital quality and payment. She leads outreach to the business, government, research and regulatory communities on behalf of the FAH.

Prior to her current role, Chambers served as Corporate Secretary at the Federation. That position had Chambers overseeing the group’s corporate activities and working with the FAH’s Board of Directors and the Board of Governors. She also served as Vice President for Legislation and Political Affairs at the FAH. In this role, Chambers represented the Federation on a wide range of key hospital issues to Members of Congress, their professional staff, and to members of the Administration. During this tenure, Chambers was also responsible for managing FedPAC, the FAH Political Action Committee.

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Prior to joining the FAH in 2003, Chambers served as Vice President of Government and Professional Affairs for the College of American Pathologists., Chambers served as Assistant Director of Congressional Affairs with the American Medical Association. Previous experience also includes her role as Executive Director of the Ripon Society and the Ripon Educational Fund. Chambers served as Legislative Assistant for Representatives James A.S. Leach (R-IA), and held the same role with Thomas J. Tauke (R-IA).

Ms. Chambers earned a Master of Business Administration degree from The George Washington University, a Bachelor of Arts degree from The College of Wooster, and has nearly completed a Bachelor of Arts degree in interior design from Marymount University. She also has significant experience in non-profit fundraising and has a post-graduate certificate in Fundraising Administration from George Washington University. Chambers is highly involved in community service projects, including her role as a Trustee of The College of Wooster where she Chairs Trusteeship and Governance. She also is involved with numerous civic activities and serves as a member of the Youth Ministries committee at her church.

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Paul F. Conlon, PharmD, JDSenior Vice President, Chief Quality and Patient SafetyTrinity Health

As Senior Vice President, Chief Quality and Patient Safety, Paul Conlon is committed to making sure Trinity Health exceeds quality standards and ensures patient safety throughout its U.S. affiliates. He is responsible for overseeing Trinity Health clinical quality and patient safety measuring, monitoring, reporting and improvement efforts. He is the operational leader of the Trinity Health Unified Clinical Organization.

Dr. Conlon brings to hands-on clinical pharmacy, academic achievement, and health care management practice experience to his current role. He is a faculty member of the University of Michigan College of Pharmacy, and has served as a clinical quality a health care consultant to General Motors Corporation. During the last 20 years, Paul has been leading clinical quality and patient safety improvement work.

Dr. Conlon earned a Doctor of Pharmacy degree from the University of Michigan, a Juris Doctorate from the University of Detroit and a bachelor’s degree in pharmacy from Northeastern University. He lends his expertise to numerous community, state and national clinical quality improvement groups, and has authored numerous articles for professional journals.

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He is the Past-Chair and current board member of the Michigan Hospital Association Keystone Center; was the Co-Chair of the National Quality Forum Medication Management Consensus Steering Committee; and was a two term member of the National Quality Forum Consensus Standards Approval Committee. For his achievements, Conlon was recognized as the first recipient of the Michigan Health and Hospital Association Patient Safety and Quality Leadership Award.

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Nancy FosterVice President for Quality and Patient-Safety PolicyAmerican Hospital Association

Nancy Foster is the Vice President for Quality and Patient Safety Policy at the American Hospital Association (AHA). In this role, she provides advice to public policymakers on legislation and regulations intended to improve patient safety and quality in America’s hospitals. Nancy is the AHA’s point person at the National Quality Forum, the Hospital Workgroup of the Measures Application Partnership, and is the liaison to the Joint Commission’s Board of Commissioners, and represents hospital

perspectives at many national meetings.

Prior to joining the AHA, Nancy was the Coordinator for Quality Activities at the Agency for Healthcare Research and Quality (AHRQ). In this role, she was the principal staff person for the Quality Interagency Coordination Task Force, which brought Federal agencies with health care responsibilities together to coordinate their work and engage in projects to improve quality and safety. She also led the development of patient safety research agenda for AHRQ and managed a portfolio of quality and safety research grants in excess of $10 million.

She is a graduate of Princeton University and has completed graduate work at Chapman University and Johns Hopkins University. In 2000, she was chosen as an Excellence in Government Leadership Fellow.

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Thomas K. French, MStatSystem Director of Clinical Analytics, Division of Clinical Effectiveness and QualityProvidence Health & Services

Thomas French is the system director of clinical analytics at Providence Health and Services. In this role, Mr. French helps lead the organization in assessing and improving system-wide performance in clinical quality and patient safety. With an extensive background in health care analytics, Mr. French joined Providence in 2009.

Prior to joining Providence, Mr. French spent seventeen years as Manager, Senior Consultant and System Director for Research Analytics at Intermountain

Healthcare. Working with Dr. Brent James in the Institute for Health Care Delivery Research, Mr. French led a team of analysts aligned with numerous clinical programs and was chief analytics consultant for an Advanced Training Program (ATP) that teaches caregivers throughout the world how to improve the quality of care in their local communities.

Mr. French also served as a biostatistician at the University of Utah Division of Biostatistics and Epidemiology for five years, followed by a role as reliability and quality engineer for Hercules Aerospace Company and as a Health Information Analyst with Alta Health Strategies in Salt Lake City.

Mr. French has co-authored several papers covering a wide range of healthcare related topics including publications in the Annals of Internal Medicine, JAMA, J. Nat’l Cancer Inst., Journal of Microbiology, Prev. Med., Am J Epidemiology, J Fam Practice, Circulation, Journal of Cardiac Failure and others.

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Stephen Horner, RN, BSN, MBAVice President, Clinical AnalyticsHCA, Inc.

Steve Horner is a recognized expert in clinical measurement, data collection, and reporting design, with more than three decades experience in the healthcare industry. Currently, he is responsible for public reporting, pay-for-performance reporting, outcomes measurement, business intelligence, and clinical analytics and reporting for HCA, Inc.

Under his leadership, HCA developed a risk-adjusted outcomes measurement and reporting application (CHOIS) and

the Clinical Outcome Measure Evaluation and Transmission (COMET) system, which has met criteria for inclusion in the accreditation and/or certification (as appropriate) process, and is included on The Joint Commission’s (TJC) list of acceptable ORYX vendors. Mr. Horner was key in developing the clinical reporting systems used to inform the HCA executive team and Board of Trustees.

He is HCA’s representative to the National Quality Forum and has served on the Hospital Quality Reporting and Nursing Sensitive Care Measures steering committees. Mr. Horner also serves on the Quality Committee and Board of Governors of the Federation of American Hospitals.

Mr. Horner earned his Bachelor of Science degree in Nursing from the University of Toledo and a Masters of Business Administration from Vanderbilt University Owen Graduate School of Management. He has served as a guest lecturer at both universities and is a former adjunct faculty member at Tennessee State University’s College of Health

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Sciences, where he taught Health Information Management, Health Care Statistics and Analytics, and Quality Assessment and Performance Improvement. Mr. Horner has also served as a Senior Program Consultant to the Robert Wood Johnson Foundation.

Prior to joining HCA, he was responsible for operations improvement consulting services for a national healthcare-consulting firm. He has also served as the Manager of Utilization/Cost Services for Humana and as Director of Quality Management at an 800-bed teaching hospital.

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Deborah Krauss, MS, BSN, RNNurse Consultant, Division of Electronic and Clinician QualityCenter for Clinical Standards and QualityCenters for Medicare & Medicaid Services (CMS)

Debbie Krauss came to CMS over five years ago and is working in the Center for Clinical Standards and Quality, Quality Measures and Value Incentives Group. Debbie leads the operations of the EHR Incentive Program for Eligible Hospitals’ eCQM reporting, as well as working with policy and standards development used in eCQMs and CMS hospital and ambulatory reporting programs.

Prior to joining CMS, Debbie worked as a Registered Nurse and has extensive clinical experience in Critical Care, Trauma, Interventional Radiology and Perioperative Nursing. She has been a clinical instructor for nursing students at the Bachelors and Associate of Arts degree levels.

Debbie received her Master’s Degree from University of Maryland at Baltimore, with a specialty in Nursing Informatics and has been working in that field for the past 15 years. She has spoken nationally on various topics related to her clinical and informatics experience.

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Kevin Larsen, MD, FACPMedical Director, Meaningful Use, Office of the National Coordinator for Health Information TechnologyCMS Lean Implementation, Office of the Administrator/ Center for Medicare & Medicaid InnovationU.S. Department of Health and Human Services

Kevin L. Larsen, MD is currently the Director Enterprise Lean Implementation, at the Centers for Medicare & Medicaid Services (CMS) in Baltimore, MD. Previously, he was the Medical Director of Meaningful Use at the Office of the National Coordinator (ONC) for Health IT. He lead the ONCs work on quality policy, measurement and improvement, including clinical decision support and registries. He has and continues to serve on a number of HHS and national groups coordinating measure policy

and measure sets. Prior to working for the federal government he was Chief Medical Informatics Officer and Associate Medical Director at Hennepin County Medical Center in Minneapolis, Minnesota. He is also an Associate Professor of Medicine at the University of Minnesota. His research includes health care financing for people living in poverty, computer systems to support clinical decision making, and health literacy. In Minneapolis, he was also the Medical Director for the Center for Urban Health, a hospital, community collaboration to eliminate health disparities.

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Lynn Lenker, BSN, MS, RN-BC, ONC, NE-BCSystem/Chief Nursing Information Officer - SSM Health CareNurse Champion - Project Beacon

Lynn Lenker holds the role of the Chief Nursing Information Officer to continue the clinical integration of technology into the SSM clinical organization. Working in the Center for Clinical Excellence she leads many teams to recognize the benefits of standardized care as a system. Ms. Lenker started the Nursing Informatics structure in SSM in 2001 and lead the nursing implementation of the SSM electronic medical record (EMR).

Lynn has been a nurse since 1977 and began her work with SSM Health

Care 15 years ago at St. Mary’s Good Samaritan in Southern Illinois as the CNO. Her work with the electronic health record (EHR) began in 2006 when she began serving as Nurse Champion for the Epic implementation. As part of this role, she also chaired Nursing Informatics 2000 - a team of multi-specialty nurses that develop nursing policy for clinical information systems. The Nursing Informatics team made significant contributions to the Healthcare Information Management and Systems Society (HIMSS) recognition of SSM Health Care’s Stage 7 EHR adoption sites. The team members also supported the standardized build and development of the documentation for the Epic implementation at a Level 6.

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In 2008, Ms. Lenker became the first CNO for SSM St. Louis. As the Chief Nursing Officer for SSM Health Care-St. Louis, she has championed the implementation of Relationship Based Care program designed to return the nurse’s focus to the bedside and the patient. The work featured teams working with Appreciative Inquiry to support care delivery. This, combined with her role with the EHR, has allowed her to introduce new and innovative workflow changes to the enhance nursing practice. She is currently certified by AACN as a nurse executive, nursing informatics and orthpaedics.

Lynn holds a Bachelors of Nursing from the University of Evansville and a Masters of Nursing from the University of Illinois, Chicago. She also serves serves on the UIC Nursing Advisory Board. Current memberships include Sigma Theta Tau, NAON, AONE, and HIMSS.

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Helen Lindsay Macfie, PharmD, FABC Chief Transformation Officer, Certified Lean LeaderMemorialCare Health System

Helen Macfie, PharmD, FABC, is Chief Transformation Officer for MemorialCare, a six-hospital, 1,600 bed not-for-profit health system including a Medical Foundation and over 2500 affiliated physicians, located in Southern California. Her passion is the pursuit of safer and the highest quality care for every patient in pursuit of the Triple Aim.

She has executive responsibility for facilitation of system-level transformation and performance improvement for MemorialCare’s population health,

clinical quality, patient safety, risk management, utilization, Lean and patient and family experience initiatives. Additional areas of responsibility include coordination of system-wide strategic planning activities, operational Value Added Teams and executive sponsorship of the system’s Physician Society Clinical Best Practice Teams.

Helen speaks nationally at forums focused on improving healthcare strategy, integration of lean principles, and on performance improvement and patient safety. She serves as faculty for IHI’s Patient Safety Executive course, and on the Board of the California Hospital Association’s Hospital Quality Institute and state Quality Committee, the Board for California Hospital Assessment and Reporting (CHART), and several California statewide advisory boards (CQC). From 2008-2010 she served on the national Malcolm S. Baldrige Examiner panel. In addition, she is a Certified Lean Leader.

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Previous to her promotion to CTO for MemorialCare in 2013, she served as Senior Vice President for Performance Improvement since 2005, receiving their highest honor – the Living Out Leadership Award (LOLA). Prior to joining MemorialCare, she served as Vice President for Performance Improvement at St. Joseph Hospital in Orange, California, where she received the CEO’s “Special Commendation” for exceptional performance. She practiced as an acute care pharmacist for 13 years prior to moving into her organizational improvement work spanning the last 20+ years.

Ms. Macfie earned her Doctor of Pharmacy degree at UCSF School of Pharmacy, San Francisco, followed by post-graduate residencies in clinical pharmacy at UCSD and in pharmacy administration at Long Beach Memorial. Her FABC – Fellow of the Advisory Board Company – was earned for completing a two-year fellowship in Leadership of the Healthcare Enterprise for the 21st Century.

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John S. Pirolo, MD Senior Vice President and Chief Medical Information OfficerAscension

John Pirolo, MD, is Senior Vice President and Chief Medical Information Officer, Ascension. In this role, Dr. Pirolo has overall leadership for clinical informatics initiatives across the integrated national health ministry. This includes guiding the overall IT system architecture in partnership with clinical informatics leaders and other stakeholders across Ascension.

Prior to becoming Senior Vice Presient & Chief Medical Informatics Officer, Dr. Pirolo served for 20 years in various

roles at Saint Thomas Health, an Ascension ministry in Nashville, Tennessee.

In 1995, Dr. Pirolo began his career as a surgeon, providing cardiovascular services at Saint Thomas West Hospital for nine years. In 2004, he moved into the role of Vice President and Chief Medical Informatics Officer for Saint Thomas Health Services, where he became Senior Vice President and Chief Medical Officer in 2013.

In 2014, Dr. Pirolo was recognized as one of the “100 Hospital and Health System CMOs to Know” by Becker’s Hospital Review.

Dr. Pirolo received a BS from The Johns Hopkins University in 1981 and went on to receive his MD from the Johns Hopkins University School of Medicine in 1985. During that time, he participated in a Sarnoff Fellowship at the University College London in 1982-1983. Dr. Pirolo completed his residency at Washington University School of Medicine, Barnes Hospital, beginning with General Surgery (1985-1989), followed by a Cardiothoracic Surgery Research Fellowship (1989-1992) and a Cardiothoracic Surgery Fellowship (1992-1995).

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Cindy Tourison, MSHIActing Director, Division of Quality Measurement Quality Measurement and Value-Based Incentives Group Centers for Medicare & Medicaid Services (CMS)

Cindy Tourison is currently the Acting Director over the Division of Quality Measurement (DQM) at CMS in the Centers for Clinical Standards and Quality. DQM provides quality measurement expertise for a large portfolio of CMS quality reporting and performance based programs, as well as expertise more generally for the agency. DQM is primarily responsible for developing, maintaining, and supporting the implementation of quality measures used in CMS quality reporting and performance based programs. DQM

also oversees quality measure data for these programs publicly, primarily through CMS Compare sites. Prior to her role as Acting Director of DQM, she led the Hospital Inpatient Quality Reporting (IQR) and Hospital Value Based Purchasing (HVBP) programs. In that role, she oversaw policy making, national education and outreach, and operationalizing requirements for each program. She worked on aligning IQR and HVBP to the EHR Incentive Program quality measures since she joined CMS in 2011. Prior to joining CMS, Cindy worked on the vendor-side of healthcare as a Client Services Manager overseeing support for several product lines. She received her Masters of Science degree in Healthcare Administration Informatics from University of Maryland University College (UMUC) in 2008 and received a Bachelor of Science Degree from Stevenson University in Business Information Systems in 1998.

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