Cardiovascular Services Regional Clinical Quality Program Manager

Position Summary

• Oversee NCDR CathPCI Registry abstraction, ensuring accuracy, outlier identification, and timely quarterly submission.
• Lead regional review and validation of STS Adult Cardiac Surgery Database (CABG, valve, combined procedures) prior to submission.
• Manage data abstraction and submission for Structural Heart registries, including TVT (TAVR, MitraClip/TMVR) and LAAO.
• Ensure high‑quality, audit‑ready data across all cardiovascular registries.

• Conduct concurrent and retrospective reviews of PCI, STEMI, AMI, CABG, and CHF cases to validate documentation, outcomes, and adherence to evidence‑based standards.
• Monitor key performance indicators such as door‑to‑balloon times, AMI mortality, CABG outcomes, CHF readmissions, and structural heart complications.
• Identify trends, variation, and opportunities for improvement across the region.

• Lead cardiovascular quality improvement initiatives using Lean, Six Sigma, PDSA models, and high‑reliability principles.
• Facilitate regional review of adverse events, complications, readmissions, and mortality, including root cause analyses and case audits.
• Develop and track action plans that drive measurable improvement in AMI, CABG, CHF, PCI, and structural heart outcomes.

• Provide education to cardiovascular teams on documentation, registry requirements, and evidence‑based clinical standards.
• Support regional Cardiology and Cardiothoracic Surgery Morbidity & Mortality processes, including data preparation and case identification.
• Collaborate with cardiology, CT surgery, structural heart, emergency medicine, critical care, and quality leaders to align pathways, protocols, and performance goals.

• Ensure readiness for Joint Commission cardiovascular standards and disease‑specific care programs (AMI, Heart Failure, CABG).
• Validate CMS IQR and eCQM cardiac measures and support compliance with evolving regulatory requirements.
• Maintain survey readiness through ongoing monitoring, mock tracers, and corrective action planning.

Responsibilities

What you will do

• Serves as a subject matter expert in clinical quality, driving improvements at the system or regional level.
• Leads and supports quality and safety initiatives, coordinates projects assigned by AVP, Quality, Regulatory, and Safety or administrative designee, and develops strategies and presentations to achieve system and/or regional quality goals.
• Analyzes outcome reports, identifies trends and areas for improvement, implements necessary actions, and compiles reports for leadership and committee review.
• Tracks and monitors quality outcomes to support continuous improvement at the system or regional level.
• Responsible for facilitating activities towards system and/or regional quality goals by developing strategies, improvement plans and presentations consistent with improvement in board quality and safety goals.
• Collaborates with leadership, clinical staff, and interdisciplinary teams, including risk management, infection prevention, regulatory, data analytics, patient experience, education, and operational effectiveness, to plan and maintain a robust quality and safety program.
• Works collaboratively with the executive team to implement quality and safety initiatives for the system or region.
• Works with leadership to foster a culture of quality, patient safety, and compliance with regulatory agency requirements.
• Identifies opportunities for process and practice improvement in the practice environment, assists in developing policies and procedures, and guides implementation at the system or regional level.
• Prepares and maintains initiatives to meet national benchmarks such as Leapfrog, CMS Star Ratings, and U.S. News & World Report.
• Participates in planning and implementing new technologies and procedures that support or enhance quality and patient safety.
• Maintains open, positive working relationships with all team members, providers, and leaders at Baptist Health.
• Maintains reasonably regular, punctual attendance consistent with Baptist Health policies, the ADA, FMLA and other federal, state, and local standards.
• Maintains compliance with all Baptist Health policies and procedures.
• Performs all other duties as assigned.
• Provides education and training related to quality and patient safety.
• Produces reports to meet the needs of the physicians, practice managers and leadership that will facilitate the identification of areas of improvement opportunity within OH and/or document progress of improvement activities.
• Serves as a resource for the staff as related to quality and safety, and to observe the daily operations within the practices to identify potential areas for process improvement or enhancements to patient safety.
• Demonstrates initiative and situational leadership skills.
• Embraces, communicates and promotes effective change.
• Maintains appropriate skill level in using current and future data platforms used by Baptist Health.

Qualifications

• Education:
  • Bachelor’s degree.
    • Masters preferred.
• Seven (7) years’ experience in acute care or other applicable healthcare settings.
  • Highly preferred: cardiovascular services and clinical quality improvement in an inpatient setting.
• Registered Nurse, Respiratory Therapy, Pharmacy, life sciences or healthcare administration. Certification.
• Certification as a Professional in Healthcare Quality Certification (CPHQ), Patient Safety (CPPS), or other approved patient safety certification within 1 year of hire.