Program Manager, Quality, Safety & Regulatory

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The Quality, Safety & Regulatory Program Manager supports the Interventional and Procedural Services Platform by coordinating quality metrics, safety event follow-up, regulatory readiness, infection prevention partnership, radiation/contrast/sedation safety tracking, high-level disinfection oversight coordination, and procedural safety standards. Reporting to the Senior Director of Quality and PI, the Program Manager works closely with the VP of Interventional Services, Senior Director of Procedural Nursing and Clinical Operations, Platform Medical Director, specialty medical directors, managers, Quality, Patient Safety, Infection Prevention, Regulatory, Radiation Safety, Pharmacy, and other partners to ensure the platform has reliable quality infrastructure and visible accountability for improvement.

This role is intended to be a central integration point for procedural quality, safety, and regulatory work. The Coordinator does not replace department-level accountability; rather, the role creates standard processes, dashboards, follow-up discipline, and escalation pathways across OR, Cath Lab, Interventional Radiology, Endoscopy, SPD, Pre/Post, and related procedural services.

Stanford Health Care Tri-Valley

• Develop, maintain, and coordinate platform quality and safety dashboards for OR, Cath Lab, Interventional Radiology, Endoscopy, SPD, Pre/Post/PACU/Procedural Recovery, and related procedural services.
• Track procedural quality indicators, infection prevention indicators, procedural complications, sedation events, radiation dose outliers, contrast events, unplanned transfers/admissions, retained item risks, specimen labeling defects, endoscope reprocessing compliance, sterilization biological indicator failures, and other agreed measures.
• Prepare routine reports for the Monthly Procedural Quality and Safety Committee, Interventional Services Executive Council, and leadership review.

• Coordinate review, classification, follow-up, and closure tracking for procedural safety events, near misses, regulatory findings, and improvement actions.
• Support root cause analysis, apparent cause analysis, action planning, audit design, and evidence collection in collaboration with Quality and Patient Safety partners.
• Ensure action plans have owners, timelines, evidence of completion, and sustainment measures.

• Coordinate procedural regulatory readiness activities, mock survey preparation, tracers, documentation audits, policy review, competency tracking evidence, and survey response support.
• Maintain readiness focus for surgical/procedural safety standards, sedation safety, high-level disinfection, infection prevention, radiation safety, contrast safety, medication safety, specimen handling, and SPD/sterilization processes.
• Partner with managers to identify gaps, elevate risks, and support timely corrective action.

• Support standardization of policies, procedures, checklists, audits, dashboards, and escalation pathways across procedural areas.
• Facilitate interdisciplinary improvement work groups as assigned, including sedation safety, procedural verification, high-level disinfection, infection prevention, radiation/contrast safety, and SPD/OR reliability.
• Promote a Just Culture, high-reliability principles, C-I-CARE, and transparent learning from events.

• Timeliness and completeness of quality dashboards, monthly reporting, action item closure, and sustainment audits.
• Safety event follow-up completion, corrective action verification, regulatory readiness scores, audit completion, and survey finding closure.
• Performance trends in sedation safety, radiation/contrast safety, infection prevention, retained item risk, specimen labeling defects, endoscope reprocessing compliance, sterilization monitoring, and procedural complications.
• Manager and physician leader satisfaction with quality reporting, escalation visibility, and improvement support.

• Bachelor's Degree in nursing, healthcare administration, quality…