Jennifer Fexis


Motivated and dedicated healthcare quality professional with directorial experience with risk, utilization, and quality management programs in the acute, rehabilitation, and home care settings.

Accomplished in team development and instilling a culture of safety. Expert knowledge in Joint Commission and OSHA standards, and Conditions of Participation and New Hampshire licensure regulations. Skilled communicator who consistently motivates staff to provide high quality healthcare to the community served.


Support clinical and non-clinical leaders to prioritize problems, collect data, analyze information and take action to develop, enhance and implement best practices to elevate patient satisfaction and improve outcomes and promote a safe environment consistent with dynamic regulations and standards.  


Personal interests include activities that maintain a balance of mind and body; running, biking, weight training, reading, writing, learning, and traveling. 

Work History

Work History
2007 - Present

Director, Performance Improvement

Franciscan Hospital for Children

  • Designed and executed organization-wide culture of safety survey used to develop quality improvement objectives resulting in overall score impact of 75% to 95% over two years.

  • Structured and delivered initial and on-going cultural competency training for managers, staff, and volunteers.

  • Developed and coordinated implementation of software solution to manage the proactive procedures and processes that support appropriate and efficient use of behavioral and medical healthcare services.

  • Led a team in successful development of a patient and family advisory council; act as project coordinator for council and implemented identified strategies resulting in improvements in satisfaction survey response from 13% to 52% response rate and revision of patient and family welcome book.

  • Established process to promote high quality care by concurrently monitoring documentation of care interventions. Led team to analyze trends and implement actions to improve timing of medical records entries from 80% to 97%; H&P timeliness from 92% to 100%; and medication reconciliation from 86% to 100%.

2005 - 2007

Director, Quality Improvement

  • Led multi-disciplinary team in developing strategies to improve DVT prophylaxis for at risk medical patients from 21% to 95% in 6 months and achieved and sustain 100% compliance with best practices to prevent surgical complications and infections.

  • Created standard order sets and associated care plans to ensure institution of appropriate care, treatment, and service for top ten DRGs.

  • Developed medical staff on-going professional practice evaluation process to allow for timely response to improve performance.

  • Created and managed survey readiness program and led team responsible for standard and regulatory compliance and organized response to unannounced surveys; coordinated three successful organizational licensure and accreditation surveys.

  • Served as quality consultant on the Cancer Committee; led efforts to improve continuity of care for cancer patients by incorporating additional rehabilitation services. 

Apr 2002 - May 2005

Quality Outcomes Manager

Nashoba Valley Medical Center
  • Lead several FMEAs and RCAs resulting in systems improvement in medication safety, falls reduction, and environmental safety.

  • Developed and implemented software solutions to ensure full life-cycle management of policies and procedures; manage operating room utilization; and manage outpatient denials.

  • Coordinated licensure and accreditation readiness program to ensure regulation and standards compliance and staff preparedness.

  • Coordinated successful surveys including 2 TJC surveys, 2 DPH licensure survey, 1 CMS survey and 2 AABB surveys.

  • Led team to implement medication reconciliation process resulting in an 92% compliance with medication reconciliation at admission, transfer, and discharge. Led Cardiac PI team resulting in an increase from 19% to 95% compliance for all care interventions for patients with heart failure and AMI. Led Pneumonia PI Team resulting in an increase from 32% to 85% for all care interventions for patients with pneumonia.


Jan 2005 - Mar 2009

Bachelor of Science degree in Business Studies

Southern New Hampshire University




Competent in the use of fundamental improvement tools to understand relationships and identify trends and patterns.

team building

Have mastered skills necessary to manage teams across departmental and organizational boundaries. 

analyzing problems

Ability to  identify patterns and causal relationships, interpret information and reach conclusions to resolve and/or improve the target problem or situation.


2008 - 2010

Certified Professional in Healthcare Quality (CPHQ)

Healthcare Quality Certification Board