Responsibilities- The Director of Surgical Quality is a senior administrative leader responsible for the development, implementation, oversight, and continuous improvement of surgical quality and safety initiatives across USA Health.
- This role serves as the principal architect and operational lead for all surgical quality programs, including but not limited to ACS NSQIP, STS, MBSQIP, NAPRC, and other surgical registries or data platforms.
- The Director will partner with surgical department leaders, clinical teams, data analysts, and the quality infrastructure to translate data into actionable improvement strategies that drive excellence in patient outcomes, regulatory compliance, and public reporting.
- Lead and manage institutional participation in national surgical quality improvement programs, including: ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program), STS (Society of Thoracic Surgeons), MBSQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program), NAPRC (National Accreditation Program for Rectal Cancer), Additional surgical registries as applicable.
- Serve as the system-wide subject matter expert for surgical quality metrics and registry data.
- Monitor and respond to publicly reported quality outcomes specific to surgical care, including but not limited to: Surgical Site Infections (SSI) in colon and hysterectomy procedures, complications associated with total hip and total knee arthroplasty, collaborate with infection prevention, surgical departments, and regulatory affairs to address quality shortfalls and maintain compliance with CMS, Leapfrog, and other rating agencies.
- Translate registry data into meaningful reports and dashboards for stakeholders including chairs of surgery, OR leadership, and executive leadership.
- Identify trends, risks, and opportunities for improvement in surgical care quality and safety.
- Coordinate and support quality improvement (QI) initiatives using evidence-based practices and data from surgical databases.
- Act as a strategic advisor to the Chief Quality Officer/Surgery on all surgical quality and safety matters.
- Foster collaborative relationships across service lines, including nursing, anesthesia, perioperative services, infection prevention, risk management, and data analytics.
- Support surgical faculty and residents with quality-related education, projects, and research.
- Completes all mandatory department, educational and hospital requirements
- Adheres to current Infection Control and Safety Standards
- Regular and prompt attendance
- Ability to work schedule as defined and overtime as required
- Related duties as assigned
Additional InformationEmployees must be in a regular position, working 20 hours or more per week (.50 FTE or greater) to qualify for benefits.
Qualifications- Bachelor's Degree and 5 years of experience in healthcare quality, performance improvement, or surgical services, with 2 years in a leadership or administrative role Required
- Experience with ACS, NSQIP, or other surgical clinical databases Required
- Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma, or equivalent quality-related certification Preferred
- Comparable combination of education and experience may substitute for the above requirements.
