Regional Clinical Quality Program Manager Cardiovascular Services

Position Summary

Regional Clinical Quality Program Manager - Cardiovascular Services

Baptist Health Alabama (Regional Role)

Baptist Health is seeking an accomplished and forward‑thinking Regional Clinical Quality Program Manager for Cardiovascular Services to lead quality, safety, and performance improvement initiatives across our five hospitals in Alabama. This leader, working in partnership with operations, cardiology, cardiothoracic surgery, structural heart teams, and nursing, will play a pivotal role in elevating outcomes for Acute Myocardial Infarction (AMI), Coronary Artery Bypass Grafting (CABG), Congestive Heart Failure (CHF), STS‑reported procedures, and Structural Heart interventions.

The role is essential to strengthening regulatory readiness and advancing performance in nationally recognized programs including the Joint Commission, CMS cardiac quality measures, STS public reporting, and U.S. News & World Report cardiology rankings.

About the Role

The Regional Clinical Quality Program Manager serves as the region‑wide expert in cardiovascular quality, safety, and performance improvement. This role partners closely with cardiology, cardiothoracic surgery, structural heart programs, emergency services, critical care, nursing leadership, and hospital quality teams to ensure consistent, high‑reliability cardiovascular care across the region.

Registry Oversight & Data Integrity

• 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, Mitra Clip/TMVR) and LAAO.
• Ensure high‑quality, audit‑ready data across all cardiovascular registries.

Clinical Case Review & Performance Monitoring

• 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.

Quality Improvement & Event Analysis

• 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.

Education, Engagement & Collaboration

• 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.

Regulatory & Accreditation Readiness

• 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.

Essential Functions.

• 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.
• Resp…