Cardiovascular Services Regional Clinical Quality Program Manager

Position Summary Cardiovascular Services Regional Clinical Quality Program Manager A Brief Overview

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.

• 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.

• Conduct concurrent and retrospective reviews of PCI, STEMI, AMI, CABG,and CHFcases 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 standard sand 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.

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…