• Region-Wide Quality Oversight: Monitor and evaluate surgical and peri-operative quality performance metrics across all Baptist Health hospitals in Alabama, ensuring alignment with CMS guidelines and internal benchmarks.
• Surgical Safety Leadership: Champion best practices in peri-operative safety, including standardized protocols for pre-op, intra-op, and post-op care. Facilitate adoption of evidence-based tools such as surgical safety checklists and time-outs.
• CMS Compliance & Reporting: Ensure accurate documentation and timely submission of surgical quality data to meet CMS requirements including IQR and eCQM measures as applicable, infection prevention (SSIs), and adverse event tracking.
• Performance Improvement: Lead multidisciplinary reviews and root cause analyses in collaboration with quality and hospital leaders to identify region-wide trends and implement corrective actions. Develop and monitor action plans to achieve measurable improvements.
• Education & Engagement: Provide training and support to peri-operative teams on regulatory standards, quality documentation, and continuous improvement strategies in collaboration with regulatory and professional development leaders.
• Regional Collaboration: Serve as a strategic liaison among surgical departments, anesthesia, infection prevention, and quality teams across all five hospitals to foster a unified culture of safety and excellence.

Education/Training

• Bachelor’s degree.
• Masters preferred

Licensure/Certification

• Registered Nurse
• Certification in healthcare quality and safety (e.g., CPHQ, CPPS) within one year of hire.

Experience 

• Seven (7) years’ experience in acute care or other applicable healthcare settings. Five (5) of the seven (7) years MUST be in perioperative services and clinical quality improvement. 
• Strong knowledge of CMS surgical quality measures and regulatory compliance.
• Ability to travel across Baptist Health facilities in Alabama as needed.