Director, Surgical Quality - UH Quality & Safety Management -

USA Health; Mobile (AL); On-site; USD 150,000 - 230,000; Full time

Job summary

USA Health seeks a Director of Surgical Quality to lead and advance surgical quality initiatives across its Gulf Coast facilities. The role oversees programs, data registries, and improvement projects to ensure patient safety and regulatory compliance.

The position partners with clinical leaders, infection prevention, and analytics to translate data into actionable strategies that elevate outcomes and reporting across the system.

Qualifications

• 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.
• Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma, or equivalent quality-related certification preferred.

Responsibilities

• Develop and oversee surgical quality programs across USA Health.
• Translate registry data into reports and dashboards for chairs, OR leadership, and executives.
• Lead institutional participation in national surgical quality improvement programs (ACS NSQIP, STS, MBSQIP, NAPRC).
• Serve as system-wide expert on surgical quality metrics and registry data.
• Monitor publicly reported quality outcomes and ensure CMS/leapfrog compliance.
• Collaborate with nursing, anesthesia, infection prevention, and data analytics to drive improvement.

Skills

Leadership

Healthcare quality

Performance improvement

Data analysis

Education

Bachelor's degree in healthcare quality or related field

Tools

ACS NSQIP database

Job description

Overview

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provides the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall well-being of our community.

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provides the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall well-being of our community.

Responsibilities

• 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 but not limited to 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.


• 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), 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.


• Completes all mandatory department, educational and hospital requirements


• Adheres to current Infection Control and Safety Standards


• Regular and prompt attendance


• Ability to work schedule as defined and overtime as required


• Related duties as assigned

Additional Information

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

Qualifications

• 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 Required


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


• 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.

Equal Employment Opportunity/Affirmative Action Employer

The University of South Alabama is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, pregnancy, sexual orientation, gender identity, gender expression, religion, age, genetic information, disability, protected veteran status or any other applicable legally protected basis. EO Employer – minorities/females/veterans/disabilities/sexual orientation/gender identity.