DIRECT DIFFERENCE TEAM

Debra Aruffo | Founder & Chief Executive Officer

Debra Aruffo is a healthcare quality executive and entrepreneur recognized for translating complex clinical and regulatory requirements into stronger data integrity, defensible performance, and protected reimbursement. As Founder and Chief Executive Officer of Direct Difference, she leads a national healthcare services company specializing in clinical quality measurement, regulatory compliance, data abstraction, education, and hospital performance improvement.

Her career began in her father’s neurosurgical practice and advanced through clinical trial work for physician groups, building a foundation in clinical research, medical documentation, and healthcare operations. She later distinguished herself in a pioneering Core Measures Coordinator role, where her leadership contributed to strong hospital quality performance and recognition. Those results led to an invitation to present her approach at an American Hospital Association workshop. Seeing a broader need for specialized expertise and practical guidance in hospital quality operations, Debra founded Direct Difference.

A defining achievement in Debra’s career was her contribution to the favorable decision in Western Medical Center–Santa Ana v. Wisconsin Physicians Service, Provider Reimbursement Review Board Case No. 08-1695. Following a federal audit and validation process with substantial financial implications, she conducted a rigorous review of disputed clinical records, uncovered discrepancies in the validation findings, and delivered expert testimony before the Board.

The Board ruled in the hospital’s favor and directed corrections to its validation score. According to the hospital’s Chief Financial Officer, the decision enabled the recovery of more than $4 million in disputed Medicare reimbursement. The outcome underscored Debra’s ability to align meticulous clinical record analysis with CMS quality requirements, validation methodology, and financial accountability.

Today, under Debra’s leadership, Direct Difference advises hospitals and healthcare organizations nationwide on clinical data abstraction, quality-measure education, and regulatory validation. The company helps clients strengthen data integrity and regulatory readiness, respond effectively to CMS-related validation and reimbursement challenges, and pursue quality recognition, including American Heart Association Achievement Awards. Through a leadership approach grounded in integrity, technical rigor, and practical partnership, Debra enables healthcare organizations to meet demanding quality requirements with confidence and safeguard the resources essential to patient care.

Misti Pacheco | Chief Operating Officer

Misti Pacheco is an accomplished healthcare executive with more than 25 years of experience spanning healthcare operations, nursing administration, financial management, technology implementation, and organizational leadership. She brings a strong blend of operational expertise, analytical insight, and strategic leadership to Direct Difference, with a focus on operational excellence, process improvement, and effective solutions that support healthcare organizations.

Misti began her healthcare career in 2000, supporting nursing administration, operational efficiency, and workforce management. Early in her career, she contributed to the development of software solutions designed to improve nurse staffing, resource allocation, and departmental efficiency. She later assumed responsibility for financial reporting within nursing administration, broadening her expertise in budgeting, financial oversight, and organizational performance.

At Tenet Healthcare, Misti served as a System Administrator, working closely with the Chief Nursing Officer to strengthen staffing processes and implement technology solutions that supported more efficient nursing operations.

Over time, her career expanded from nursing administration into hospital administration, where she spent eight years of her tenure developing a broader, enterprise-level perspective on hospital operations, organizational priorities, and executive decision-making. This experience strengthened the operational and strategic foundation she later brought to Direct Difference.

Misti joined Direct Difference in 2011 in contract management, bringing a strong foundation in healthcare operations, financial management, and business processes. Recognized for her leadership and contributions to operational performance, she advanced to Chief Operating Officer in 2014. Her progression reflects a deep understanding of how operations, financial stewardship, technology, and strategic execution align to drive organizational growth.

As Chief Operating Officer, Misti provides executive leadership and operational oversight for Direct Difference, helping shape business strategy, strengthen internal processes, and ensure consistent delivery of high-quality services. She is committed to continuous improvement, collaborative leadership, and responsive client service. Her ability to connect operational strategy, financial discipline, and organizational priorities helps Direct Difference adapt to evolving client needs, strengthen performance, and deliver lasting value.

Ashley Ward | Director of Operations

Ashley Ward has more than 15 years of healthcare experience spanning medical chart abstraction, quality reporting, hospital administration, and nursing workforce coordination. She draws on this experience to align operational priorities with clinical and administrative requirements. Inspired by family members in healthcare, she has built a career grounded in service, professional growth, and commitment to Direct Difference’s healthcare partners.

Ashley joined Direct Difference in 2010 as a Medical Chart Abstractor, building a foundation in clinical documentation and quality reporting. Experience in hospital administration and nursing workforce coordination broadened her understanding of clinical workflows, staffing, and hospital operations. At a national nurse staffing agency, she helped healthcare organizations assess workforce demands and develop staffing solutions.

Ashley assumed progressively greater responsibilities at Direct Difference, earning multiple promotions before advancing to Director of Operations. Her progression from chart abstraction to operational oversight connects firsthand quality reporting experience with organizational priorities. Her clinical support, administration, and staffing background provides a broad understanding of interconnected workflows and workforce demands.

As Director of Operations, Ashley aligns internal workflows, team coordination, and service delivery with healthcare partner needs. Her leadership priorities center on process improvement, efficient operations, responsive client support, and reliable solutions to daily challenges. She brings a clinical and administrative perspective to these responsibilities, balancing organizational requirements with the practical demands of healthcare delivery.

Brenda Clemens, RN, CPHQ | Chief Quality Officer

Brenda Clemens is a healthcare quality executive and Registered Nurse with more than 40 years of leadership experience across patient safety, performance improvement, accreditation, nursing, and consulting. She advises healthcare organizations on strengthening quality oversight, safeguarding data integrity, and translating evidence-based practices into sustained operational and clinical performance.

Her career encompasses the design and leadership of initiatives that strengthen performance measurement and reporting, advance accreditation readiness, facilitate Root Cause Analyses (RCAs), and embed cultures of safety and high reliability. In collaboration with the United Nations, she contributed to the development of an event reporting system, an RCA response program, and Just Culture education—initiatives that expanded reporting, strengthened organizational learning, and reduced adverse events.

Brenda holds a master’s degree in Patient Safety Leadership from the University of Illinois Chicago and a Bachelor of Science in Health Care Administration. She is a Certified Professional in Healthcare Quality (CPHQ) and a Six Sigma Green Belt, bringing together clinical expertise, executive judgment, and disciplined process improvement.

As Chief Quality Officer at Direct Difference, Brenda sets the strategic direction for quality, data accuracy, regulatory compliance, and performance improvement. She converts abstraction findings, quality trends, and performance data into executive-level insights that enable healthcare organizations to anticipate risk, close performance gaps, and demonstrate measurable progress. Through rigorous oversight and collaborative leadership, she advances Direct Difference’s commitment to trusted data, client confidence, and sustained improvements in quality, patient safety, and organizational performance.

Sherry Watson Lawler, MBA, BSN, CPHQ | Associate Quality Officer

Sherry Watson Lawler is a healthcare quality and patient safety executive with more than 26 years of leadership experience in hospital quality management, accreditation, regulatory compliance, clinical quality measurement, and performance improvement. She brings an enterprise-level perspective to advancing patient safety, strengthening regulatory readiness, and improving organizational performance.

Throughout her career, Sherry has led multidisciplinary quality initiatives and translated complex regulatory requirements into actionable improvement strategies. As Director of Quality and Patient Safety at UCLA Health, she led enterprise-wide quality and patient safety programs, oversaw clinical data registries, and reported performance outcomes to the Governing Board. As a Nurse Hospital Surveyor with The Joint Commission, she evaluated healthcare organizations against accreditation and quality standards. Earlier, at OneLegacy, she helped implement quality assessment and performance improvement initiatives and streamline clinical protocols to improve organ donation and recovery performance.

Sherry holds an MBA from Pepperdine University and a Bachelor of Science in Nursing from the University of Santo Tomas. She is a Certified Professional in Healthcare Quality (CPHQ) and holds Lean Academy Gold Level certification from UCLA. Her expertise includes quality governance, CMS reporting, accreditation, root cause analysis, performance gap analysis, and interdisciplinary change management. She also serves on the governing boards of Nevada Donor Network and South Florida Donor Network.

As Associate Quality Officer at Direct Difference, Sherry provides clinical quality oversight to help hospitals strengthen abstraction accuracy, CMS quality reporting, and regulatory readiness. She partners with teams to align quality assurance, data validation, and performance improvement with organizational priorities, translating findings into actionable insights that help clients address performance gaps, mitigate regulatory risk, and make informed decisions. Her focus is on advancing data integrity, accountability, and sustainable quality improvement across the healthcare organizations Direct Difference serves.

Mandy Budny, RN, MSN, CPHQ | Clinical Director of Education and Public Reporting

After an introduction to the healthcare field serving as a Medical Specialist in the U.S. Army, Mandy started her nursing career knowing that she wanted to impact healthcare in a broader, more administrative way.  She quickly moved into the field of quality improvement just 2 years later and moved from Performance Improvement Coordinator to Director of Quality and Risk Management in only 3 years.  She has devoted almost her entire 17 year nursing career to quality improvement having had oversight for numerous areas to include Performance Improvement, Risk Management, Medical Staff, Infection Prevention, and Environment of Care.  Project implementation is nothing new as she also has experience implementing, and seeing through to accreditation, 2 medical residency programs.  Mandy’s diverse background in healthcare administration brings a wealth of knowledge to her role with Direct Difference.  She has a Master of Science in Nursing Degree and has held CPHQ certification for 13 years.

Deborah Liverman, RN, BS | Seniors Account Manager | STS/Thoracic Data Registry Specialist

Deborah Liverman, RN, BS, with over 40 years of nursing experience including 10 years of critical care experience and management of a Stepdown unit.  For the past 18 years, Debbie has supported quality improvement as a Registry Site Manager providing oversight of STS Cardiac, STS Thoracic, NCDR ICD, and more recently NCDR TVT and LAAO Registries for a multi-facility health system.  Debbie routinely participates in multiple state-wide cardiac quality consortia where best practices are shared to improve process of care and documentation associated with registry data requirements.  She stays up to date with NCDR and STS requirements by attending the annual conferences as well as joining the monthly data manager calls.  Debbie brings a wealth of knowledge, experience, and expertise to Direct Difference as an Account Manager and Direct Difference STS Registry Expert.  Publications:  Implementation of a Continuous Quality Improvement Program for Percutaneous Coronary Intervention and Cardiac Surgery in a large community hospital.  American Heart Journal (Volume 152, Issue 2).