Director, Quality Management – Cardiovascular Quality and Data Registries

University of Miami•Hialeah, FL

About The Position

The Director, Quality Management – Cardiovascular Quality and Data Registries oversees the administration of assigned clinical quality improvement and quality management programs and initiatives, inclusive of Cardiovascular Service Line and Clinical Data Registries. The incumbent provides strategic leadership in quality management, clinical data registries, accreditation readiness, and performance improvement. This role is responsible for overseeing quality initiatives, data integrity, compliance, and patient safety across the hospital. The incumbent ensures timely and accurate data collection, analysis, and reporting, driving decision-making that enhances patient care outcomes. This position collaborates with clinical, operational, and IT leadership to optimize registry participation, improve performance on national, state, and locally reported measures, and ensure compliance with The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and other regulatory agencies. Oversees all aspects of clinical data registries, particularly cardiac and high-impact clinical registries. Supports the Department of Cardiovascular Services by overseeing registry performance, ensuring accurate and timely data submission for accreditation readiness, and coordinating weekly Mortality and Morbidity (M&M) conferences. Develops and implements hospital-wide quality and performance improvement strategies aligned with national benchmarks. Directs evidence-based quality improvement methodologies (e.g., Lean Six Sigma, Plan-Do-Study-Act). Ensures alignment of quality performance metrics with organizational priorities. Monitors changes in registry requirements to ensure timely, accurate data submissions, maintaining full compliance with state and national standards. Manages data collection, validation, analysis, and submission for all assigned registries. Ensures timely and accurate data submissions for accreditation and regulatory compliance. Partners with clinical and operational leaders to ensure data from clinical registries drives improvements aligned with the organization’s strategic priorities. Oversee registry data audits and compliance with national data standards. Develops and continuously monitors an internal reporting structure for quality management and related activities. Ensures the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process. Maintains a comprehensive inventory of current registries and performance standings, providing regular updates to leadership. Serves as the primary liaison for new registry requests, coordinating with clinical teams, IT, legal, and external vendors to streamline onboarding processes. Educates faculty, administration, and staff in the identification of opportunities for improvement and methods of collecting, analyzing, and reporting of findings and improvement strategies Serves as a representative and/or liaison with the various hospitals, committees and departments concerning quality management related matters, expediting efficiency of action to the maximum extent possible Coordinates agendas and prepares and delivers reports at various committee meetings including, but not limited to, all Performance Improvement committees, Medical Executive Committee, and Board of Governors This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

Requirements

Requires a bachelor’s degree in nursing with a valid State of Florida Registered Nurse license or equivalent experience.
Minimum of 5 years’ experience in quality management leadership role, reporting and analysis in a clinical or healthcare environment with strong broad clinical background.
Must have experience leading teams responsible for healthcare analytics and clinical registries.
Effective relationship management skills and ability to build successful collaborations across programs and multidisciplinary teams
Excellent proficiency with Microsoft Office Suite programs, Excel (pivot tables), PowerPoint, Word, and complex data analysis.
Strong understanding of statistical software and qualitative data management.
Advanced or expert knowledge of PC applications, Microsoft Office related tools to formulate complex queries to extract system data.
Has experience extracting, analyze database elements, develop spreadsheets, word processing and other applications to present statistical data, reporting trends, and measuring performance.
Excellent analytical and problem-solving skills required, including a thorough understanding of how to interpret business and user needs and translate them into technical requirements.
Commitment to University Values: Diversity, Integrity, Responsibility, Excellence, Compassion, Creativity, Teamwork.
Knowledge of business statistics, quantitative methods, performance analysis, and development of business performance dashboards, scorecards and/or KPIs.
Excellent leadership, management, and performance management skills required.
Excellent technical skills: Demonstrated excellence in computer applications, inclusive of the ability to learn new applications and programs; excellent typing skills.
Professionalism: Ability to incorporate national professional organization as well as business unit and health system’s goals to improve patient safety and quality outcomes.
Excellent interpersonal and presentation skills: Ability to promote and sustain outstanding interpersonal and customer service skills (verbal and written) while accepting responsibility to ensure all working relationships are respectful and professional.
Ability to collaboratively communicate critical guidelines and requirements to a broad range of clinicians and non-technical staff that obtain the desired results in a collegial manner.
Ability to work independently with minimal supervision, while successfully managing the prioritization and execution of multiple deadline-driven projects for a team of people and sustaining a high-level of proficiency individually and as a team.
Proven ability to help guide programs and manage employees, with a wide range of skills and experience, at all levels in the company.
Excellent attention to detail: Demonstrated ability to accurately review, screen and enter data.
Excellent communication and presentation skills: Ability to communicate questions, ideas, and solutions verbally clearly, effectively, and respectfully and in writing to a broad spectrum of specialized skill and clinical experience.
Ability to conform to shifting priorities, demands, and timelines through analytical and problem-solving capabilities
Ability to ensure consistent and accurate adherence to established workflows and processes.
Required ability to sustain mature judgement and maintain strict confidential information and patient confidentiality as mandated by HIPAA, and University policies, always respect the rights and privacy of others.
Required to maintain current knowledge and practice in compliance with standards established by external regulatory agencies that impact job performance and deliverables and maintain active licenses / certifications as deemed required by minimum requirements for position, e.g., maintain sufficient knowledge of healthcare quality programs and activities to ensure hospital and medical staff activities are following regulations.

Nice To Haves

Certified Professional Healthcare Quality preferred.
Demonstrated Registry expertise, e.g. American College of Cardiology (ACC) Registries, Society of Thoracic Surgery Registries and Get with The Guidelines (GWTG) Stroke and Heart Failure Registries and etc.

Responsibilities

Oversees all aspects of clinical data registries, particularly cardiac and high-impact clinical registries.
Supports the Department of Cardiovascular Services by overseeing registry performance, ensuring accurate and timely data submission for accreditation readiness, and coordinating weekly Mortality and Morbidity (M&M) conferences.
Develops and implements hospital-wide quality and performance improvement strategies aligned with national benchmarks.
Directs evidence-based quality improvement methodologies (e.g., Lean Six Sigma, Plan-Do-Study-Act).
Ensures alignment of quality performance metrics with organizational priorities.
Monitors changes in registry requirements to ensure timely, accurate data submissions, maintaining full compliance with state and national standards.
Manages data collection, validation, analysis, and submission for all assigned registries.
Ensures timely and accurate data submissions for accreditation and regulatory compliance.
Partners with clinical and operational leaders to ensure data from clinical registries drives improvements aligned with the organization’s strategic priorities.
Oversee registry data audits and compliance with national data standards.
Develops and continuously monitors an internal reporting structure for quality management and related activities.
Ensures the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process.
Maintains a comprehensive inventory of current registries and performance standings, providing regular updates to leadership.
Serves as the primary liaison for new registry requests, coordinating with clinical teams, IT, legal, and external vendors to streamline onboarding processes.
Educates faculty, administration, and staff in the identification of opportunities for improvement and methods of collecting, analyzing, and reporting of findings and improvement strategies
Serves as a representative and/or liaison with the various hospitals, committees and departments concerning quality management related matters, expediting efficiency of action to the maximum extent possible
Coordinates agendas and prepares and delivers reports at various committee meetings including, but not limited to, all Performance Improvement committees, Medical Executive Committee, and Board of Governors