Manager, Quality Improvement (Surgical Services)

About the role

The Manager, Quality Improvement – Surgical Services provides operational leadership for all quality improvement (QI), patient safety, and performance improvement activities within the Department of Surgery. They lead and execute the administrative, strategic, and clinical direction of the Surgical Quality and Patient Safety Program in collaboration with the Medical Director of Surgical Quality and Safety.

Responsibilities

• Provides operational leadership for all quality improvement (QI), patient safety, and performance improvement activities within the Department of Surgery.
• Leads and executes the administrative, strategic, and clinical direction of the Surgical Quality and Patient Safety Program in collaboration with the Medical Director of Surgical Quality and Safety.
• Oversees and manages the day-to-day management of surgical quality infrastructure, ensuring alignment with enterprise quality and safety priorities.
• Promotes multidisciplinary teams to achieve measurable, data-driven improvements.
• Serves as the primary point of accountability for departmental surgical quality work, translating strategic priorities into executable improvement initiatives, ensuring methodological rigor, and supporting sustainment of gains.
• Works alongside a team of clinical experts to formulate, drive, and lead projects (from idea inception through implementation and sustainment of results) using process improvement methodologies (e.g., Lean, Six Sigma, PDSA), project management strategies, facilitation, and change management to achieve improvements in operational and/or clinical outcomes.
• Oversees the planning, execution, monitoring, and sustainment of multidisciplinary surgical QI initiatives.
• Supports identification and prioritization of improvement opportunities using data analysis, safety events, audits, patient feedback, and frontline input.
• Collaborates with analytics, registry teams, and clinical leaders to define meaningful measures and monitor outcomes and process reliability.
• Supervises the creation of dashboards and collection, coding, validation, and analysis of data used to guide performance improvement activities.
• Ensures timely review, interpretation, and dissemination of surgical quality data, including dashboards, scorecards, and external benchmark reports.
• Prepares and presents concise, actionable reports for surgical leadership, quality councils, and governance committees.
• Provides direct supervision, coaching, and performance management for surgical quality improvement staff.
• Mentors clinicians and operational leaders in improvement science and change management.
• Promotes a culture of psychological safety, accountability, and continuous learning.
• Serves as a key partner to surgeons, nursing leaders, perioperative services, and administrative stakeholders.
• Facilitates effective multidisciplinary collaboration across service lines and care settings.
• Represents the Department of Surgery in organizational quality, safety, and performance improvement forums as assigned.
• Maintains oversight of the implementation and effectiveness of action plans to ensure sustained improvement.
• Identifies trends and sentinel events; assists with outlining corrective action plans, which includes preparation and implementation of clinical protocols and practice-management guidelines in conjunction with senior leadership.

Requirements

• Bachelor’s degree in healthcare, nursing, public health, quality, or a related field required.
• Master’s degree in healthcare administration, nursing, public health, quality, or a related field strongly preferred.
• Minimum of 7 (seven) years professional quality or improvement experience required; 10+ years experience preferred.
• Progressive experience in healthcare quality improvement, patient safety, or performance improvement required.
• Demonstrated experience leading multidisciplinary improvement initiatives in a complex healthcare environment required.
• Strong knowledge of quality improvement methodologies, data analysis, and change management required.
• CPHQ required upon hire.
• LSSGB preferred.
• Experience supervising or mentoring quality improvement professionals preferred.
• Pediatric clinical and/or experience in surgical, perioperative, or procedural care settings preferred.