Director, Surgical Quality - UH Quality & Safety Management -

About the Role

USA Health is transforming medicine along the Gulf Coast to care for the unique needs of our community. 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 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.

Responsibilities

• 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), and 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.
• Complete all mandatory department, educational, and hospital requirements.
• Adhere to current Infection Control and Safety Standards.
• Ensure regular and prompt attendance.
• Work scheduled hours as defined and overtime as required.
• Perform related duties as assigned.

Requirements

• 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.
• Experience with ACS, NSQIP, or other surgical clinical databases.

Qualifications

• 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.

Benefits

Employees must be in a regular position, working 20 hours or more per week (.50 FTE or greater) to qualify for benefits.