Position Objective:

The Cardiac Surgery Quality Coordinator is a critical role dedicated to advancing patient outcomes and operational excellence within the adult cardiac surgery program. This position is responsible for the comprehensive review and management of all Adult Cardiac Society of Thoracic Surgeons (STS) quality metrics. The Coordinator serves as the primary liaison between external data abstractors and internal clinical teams, seeking to educate partners on areas of operational excellence, areas for process improvement, and any areas where quality improvement are needed. Leveraging strong clinical expertise, the Coordinator will collaborate with surgical, anesthesia, and nursing partners to identify, develop, and lead targeted quality improvement initiatives.

Essential Job Duties:

Quality Improvement, Education & Clinical Collaboration

1.      Clinical Liaison: Act as the primary bridge between the external data abstraction team and internal clinical staff, ensuring seamless communication and mutual understanding of quality goals.

2.      Clinical Education & Feedback: Proactively educate multidisciplinary partners (surgeons, anesthesia, nursing) on STS metrics, highlighting current areas of operational excellence, identifying specific opportunities for process and quality improvement, and leading quality improvement data conferences.

3.      Process Improvement: Design, implement, and manage key quality improvement (QI) projects based on STS data findings to enhance patient safety, streamline clinical workflows, and improve post-operative outcomes.

4.      Protocol Development: Collaborate with clinical leadership to update or establish evidence-based care protocols, standardizing pathways for cardiac surgery patients based on identified areas of need.

5.      External Liaison: Represents Luminis Health in Maryland Cardiac Surgery Quality Initiative (MCSQI) conferences, data workshops and/or research efforts, and participates in state-level Cardiac Surgery Quality forums as appropriate.

6.      Participate in all Maryland Health Care Commission (MHCC) program review requests.

Data Management & STS Registry Oversight

1. Metric/Data Analysis: Continuously monitor and analyze adult cardiac STS quality metrics, identifying trends, outliers, and systemic gaps to drive educational efforts, and complete rigorous clinical reviews of abstracted data against electronic medical records to ensure 100% accuracy.

8.      External Abstraction Management: Oversee the efforts of the external clinical data abstraction group, ensuring timely, complete, and highly accurate data capture.

9.      Performance Reporting: Prepare and present comprehensive, actionable quality performance reports to surgical leadership and frontline teams.

10. Regulatory Compliance. Ensures all data submissions are submitted timely to the MCSQI group & the MHCC.

Educational/Experience Requirements:

• Bachelor of Science in Nursing (BSN) required; Master of Science in Nursing (MSN) or related healthcare administration degree preferred.
• Current Registered Nurse (RN) license.
• Minimum of 3–5 years of recent clinical nursing experience in cardiovascular or cardiothoracic surgery (e.g., CVICU, Cardiac OR, or Cardiovascular Step-Down).
• Demonstrated working knowledge of the STS Adult Cardiac Surgery Database definitions, metrics, and reporting structures.
• Prior experience in clinical quality improvement, process improvement methodologies, registry management, and complex data analysis is highly preferred.