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Position Summary
Baptist Health Alabama Region Baptist Health is seeking a dedicated, experienced Regional Clinical Quality Program Manager to lead peri-operative quality initiatives across its five hospitals in Alabama. This regional role is instrumental in enhancing surgical safety, ensuring compliance with CMS surgical quality measures, and driving continuous improvement in patient outcomes. The Regional Clinical Quality Program Manager serves as a subject matter expert and member of the quality team. Their role includes leading, coordinating, and supporting quality activities and projects at a system or regional level. This position is limited to regional or corporate quality departments.Responsibilities
- Region-Wide Quality Oversight: Monitor and evaluate surgical and peri-operative quality performance metrics across all Baptist Health hospitals in Alabama, ensuring alignment with CMS guidelines and internal benchmarks.
- Surgical Safety Leadership: Champion best practices in peri-operative safety, including standardized protocols for pre-op, intra-op, and post-op care. Facilitate adoption of evidence-based tools such as surgical safety checklists and time-outs.
- CMS Compliance & Reporting: Ensure accurate documentation and timely submission of surgical quality data to meet CMS requirements including IQR and eCQM measures as applicable, infection prevention (SSIs), and adverse event tracking.
- Performance Improvement: Lead multidisciplinary reviews and root cause analyses in collaboration with quality and hospital leaders to identify region-wide trends and implement corrective actions. Develop and monitor action plans to achieve measurable improvements.
- Education & Engagement: Provide training and support to peri-operative teams on regulatory standards, quality documentation, and continuous improvement strategies in collaboration with regulatory and professional development leaders.
- Regional Collaboration: Serve as a strategic liaison among surgical departments, anesthesia, infection prevention, and quality teams across all five hospitals to foster a unified culture of safety and excellence.
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Qualifications
Education/Training
- Bachelor’s degree.
- Masters preferred
Licensure/Certification
- Registered Nurse
- Certification in healthcare quality and safety (e.g., CPHQ, CPPS) within one year of hire.
ExperienceÂ
- Seven (7) years’ experience in acute care or other applicable healthcare settings. Five (5) of the seven (7) years MUST be in perioperative services and clinical quality improvement.Â
- Strong knowledge of CMS surgical quality measures and regulatory compliance.
- Ability to travel across Baptist Health facilities in Alabama as needed.
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