RN-Trauma Performance Improvement Coordinator-Trauma Program

Job Objective:

Effectively coordinates all aspects of the trauma performance improvement and patient safety processes including systems and peer review processes. The RN Trauma Performance Improvement (P.I.) Coordinator will be responsible for the maintenance of processes related to multidisciplinary trauma peer review and internal trauma systems issues including case reviews, identification of issues (provider and system), tracking and trending of complications/audit filters/issues, and maintenance of appropriate files and data systems. Demonstrates initiative, resourcefulness and problem solving skills. Demonstrates detailed knowledge of trauma hospital Performance Improvement and Patient Safety (PIPS) requirements, the trauma standard of care across the continuum and the operations of the hospital trauma system

Essential Responsibilities:

• Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
• Ensures the appropriate identification of cases requiring review. Completes chart/case review on all deaths, selected of audit filters, selected complications, systems issues and clinical issues. Ensures the appropriate tracking system for all cases, reports, and issues. Follows through to ensure the timely response to all identified issues.
• Works closely with all departments and divisions that interface with the trauma patient to facilitate the PIPS/peer review processes including all aspects of the loop closure process (case review, data review, literature review, root case analysis, ad hoc meetings, development of policies, evidence based practice management guidelines, and collaborates with all departments on their implementation and evaluation of corrective actions).
• Effectively Participates in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) fulfilling all aspects of the TQIP agreement including but not limited to the following: ensuring data submission, review of TQIP data validation reports in collaboration with the TPD and Trauma Registrars, completion of the monthly tests, participation in webinars and conferences, and other duties as assigned. Participates in local, regional and national meetings, conferences, trauma PI initiatives.
• Prepares cases for review at the monthly multidisciplinary peer review meeting. Participates in the preparation of meeting packets and completes meeting minutes in a timely and accurate manner. Reports trauma audit filter information in committee meetings as appropriate. Participates in preparations for all designation and verification trauma site surveys.
• Works in collaboration with the Trauma Program Director, Trauma Medical Director, and others to evaluate the effectiveness and appropriateness of care and policies and procedures.
• Assesses the need for and facilitates the development of compliance with trauma protocols, guidelines, pathways, and standard order sets.
• Facilitates injury prevention activities based upon local and regional data.
• Attends annual TQIP and Society of Trauma Nurses conference.

Essential Skils:

• Ability to take initiative, be innovative and work effectively in a variety of settings
• Proficient Microsoft Office programs
• Requires strong customer service, problem solving, project management and teamwork skills
• Strong interpersonal, organizational and analytical skills
• Written and verbal communication skills
• Ability to establish-maintain positive interpersonal relationships with all levels of the organization
• Ability to plan, organize and prioritize multiple tasks-projects; ability to influence and negotiate