Trauma Performance Improvement Specialist-Full Time Days

1 month ago

Fredericksburg, United States Mary Washington Healthcare Full time
Start the day excited to make a difference...end the day knowing you did. Come join our team.

Job Summary:
The Trauma PI Specialist will serve as the coordinator for performance improvement and patient safety activities for Trauma Services, which includes oversight of the Trauma Registry and Registrars, quality indicators, data analysis, trending, and report preparation to help guide outreach, injury prevention and educational activities based on data.

Essential Functions & Responsibilities
  • Collaborates with the Trauma Program Manager and Trauma Medical Director to develop and maintain a set of quality indicators for the trauma program to ensure teammates in all departments dealing with the care of the trauma patients are knowledgeable about the Trauma Program and standards of care.
  • Coordinates activities with the Trauma Medical Director and Trauma Program Manager to facilitate overall Trauma Program quality and consistency. Executes the Trauma PI Plan to monitor, evaluate, and improve the performance of the Trauma Program.
  • Reviews the PI continuum of care beginning with the prehospital setting through hospital discharge (which may include multiple inpatient and ancillary units) and determination of compliance with patient care protocols, policies, procedures, and established standards of care. Works with the trauma program leadership to ensure compliance with the regulatory requirements of the American College of Surgeons, Committee on Trauma, and the Virginia Office of Emergency Medical Services Trauma Division to maintain a consistent state of verification readiness. Supervises the validation, preparation, and submission of trauma data to the VA OEMS, National Trauma Data Bank, and ACS, COT Trauma Quality Improvement Program.
  • Manages the Trauma PI database in accordance with ACS and State guidelines.
  • Conducts the collection, surveillance, data entry, analysis and reporting of trauma quality and performance information from medical records as well as other resources.
  • Through the use of the trauma registry, peer review information, and other relevant databases, provides a standardized set of analytical, statistical, and reporting strategies for a variety of patients or provider outcomes, to be reviewed by internal and external review committees.
  • Communicates existing or potential trauma performance improvement issues and opportunities identified in trauma case evaluation and reports trending to the Trauma Program Manager and Trauma Medical Director.
  • Prepares various PI reports for meetings, data analysis, issue identification, and issue resolution, including loop closure.
  • Provides support functions for all aspects of the trauma program. May respond to Trauma Activations during normal working hours to act as a resource person and liaison for the Emergency Department and pre-hospital care providers, including EMT's, paramedics, and flight crews.
  • Assists the Trauma Program Manager with the development of the Trauma Resource Nurse role as well as the education and implementation of new trauma staff and processes.
  • Coordinates with the Trauma PI Coordinator in the investigation, analysis, and responses to quality/patient safety issues, events, significant care issues, or trends.
  • Provides oversight of the Trauma Registry and Staff to ensure data is accurate and timely.
  • Participates in local, regional, state, and national organizations to expand knowledge and program development.
  • Performs other duties as assigned.
Qualifications
  • Bachelor's Degree in nursing required, MSN preferred.
  • Licensed Registered Nurse by the State of Virginia or compact state required.
  • CPR, ACLS, and PALS required.
  • TNCC, ENPC, CEN, TCRN preferred.
  • 3-5 years' experience in Emergency, Trauma Outreach, Critical Care, education/clinical education, Performance Improvement, or Trauma Registry required.
  • Knowledge of chart abstraction and the trauma registry, including reporting, data analysis, trend identification and benchmarking of outcomes based on the American College of Surgeons, Committee on Trauma standards and recommendations for quality and maintenance for trauma center verification/reverification required.
  • Proficient in data analysis of trauma program studies, including clinical, quality, administrative, epidemiologic, research, and prevention required.


As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.

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