Women's Services Regional Clinical Quality Program Manager

Position Summary Regional Clinical Quality Program Manager - Women's Services Baptist Health Alabama (Regional Role) Baptist Health is seeking an accomplished and forward‑thinking Regional Clinical Quality Program Manager for Women’s Services to lead maternal, neonatal, and gynecologic quality initiatives across our five hospitals in Alabama. This leader, in partnership with operations, providers, and nursing, will play a pivotal role in elevating clinical outcomes, strengthening regulatory readiness, and advancing performance in nationally recognized quality programs including the Joint Commission, CMS maternal health measures, and U.S. News & World Report (USNWR) maternity rankings. The Regional Clinical Quality Program Manager serves as the region‑wide expert in women’s services quality, safety, and performance improvement. This role partners closely with obstetrics, maternal–fetal medicine, neonatology, gynecology, nursing leadership, and hospital quality teams to ensure consistent, high‑reliability care across the region. Regional Quality & Regulatory Oversight Monitor maternal, neonatal, OB ED, and women’s surgical quality metrics across all hospitals. Ensure alignment with CMS maternity and neonatal measures (PC‑02, PC‑06, PC‑07, postpartum hemorrhage, unexpected extubation, etc.) and internal benchmarks. Lead compliance with Joint Commission Perinatal Care (PC) standards and support readiness for Advanced Certification in Perinatal Care (ACPC). Coordinate survey readiness activities, mock tracers, and corrective action plans across L&D, postpartum, NICU, and GYN units. Performance Optimization: CMS, USNWR & Safety Strengthen performance in USNWR Best Hospitals for Maternity Care, improving C‑section rates, newborn complications, breastfeeding support, and patient experience. Oversee accurate documentation and submission of CMS IQR and eCQM data; validate performance and close documentation gaps. Champion AIM bundles, maternal early warning systems, and neonatal resuscitation best practices to reduce preventable harm. Lead safety huddles, simulations, and debriefs to reinforce high‑reliability practices. Quality Improvement & Event Review Lead regional improvement initiatives using Lean, Six Sigma, and high‑reliability methods. Conduct maternal, neonatal, and OB emergency event reviews, including RCAs and case audits. Develop and monitor action plans that drive measurable, sustainable improvement. Education, Engagement & Collaboration In partnership with regional professional development practitioners, train clinical teams on regulatory standards, documentation, and evidence‑based practice. Partner with nursing education and medical staff leadership to strengthen competency and consistency. Serve as liaison among obstetrics, OB ED, MFM, neonatology, gynecology, anesthesia, infection prevention, and quality teams. Align pathways, safety protocols, and quality goals across all hospitals and support system‑level strategy for women’s services. Responsibilities Essential Functions. 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 such as Leapfrog, CMS Star Ratings, and U.S. News & World Report. Participates in planning and implementing new technologies and procedures that support or enhance quality and patient safety. Maintains open, positive working relationships with all team members, providers, and leaders at Baptist Health. Maintains reasonably regular, punctual attendance consistent with Baptist Health policies, the ADA, FMLA and other federal, state, and local standards. Maintains compliance with all Baptist Health policies and procedures. Performs all other duties as assigned. Qualifications Education/Training Bachelor's degree. Masters preferred. Highly preferred: RN, BSN. Licensure/Certification Registered Nurse, Respiratory Therapy, Pharmacy, life sciences or healthcare administration. Certification as a Professional in Healthcare Quality Certification (CPHQ), Patient Safety (CPPS), or other approved patient safety certification within 1 year of hire. Experience Seven (7) years’ experience in acute care or other applicable healthcare settings. Highly preferred: women's services and clinical quality improvement. #J-18808-Ljbffr