Trauma Performance Improvement Coordinator

• Coordinates the Trauma Performance Improvement/Patient Safety (PIPS) Program for the hospital in collaboration with the TMD and TPM.
• Conducts patient rounds while utilizing clinical expertise to aggregate, assess and interpret information in order to evaluate the quality of clinical care, and the review of appropriate services.
• Review patient occurrences, user defined indicators, and audit filters with Trauma registrar and validate data on a concurrent basis.
• Responsible for issue identification, issue validation, issue analyses, and initiates follow-up to assure loop closure to improve clinical outcomes and patient care.
• Identify areas for improvement and education; using this data to develop educational programs, action plans to address quality issues identified and to ensure follow through of developed plans.
• Oversees the collection, tracking and benchmarking of trauma PI issues related to patient care and system development.
• Correlates outcomes and PI findings with trauma registry data for adherence to the Trauma.
• Program registry criteria, accuracy, and inter-relater reliability and educates registry staff as needed to ensure required compliance for trauma center accreditation.
• Provides concurrent feedback and issue resolution to the trauma service and liaison.
• Maintenance of the Trauma Registry database to ensure adequate documentation as required by the National Trauma Database, ability to produce clear effective reports and to track issues over time.
• Update Trauma database on a daily basis using concurrent and retrospective review of patient care including transfer patients.
• Ensure that all pertinent issues are entered into Trauma Registry as they occur.
• Describe all pertinent details of each issue in an agreed upon format.
• Tracks loop closure/resolution in Trauma Registry.
• Assist the TMD and the TPM to evaluate the effectiveness of the Trauma Team and the Trauma Program.
• Produces and analyzes trended data and provider specific profiles in collaboration with the TPM.
• Assist in the preparation of any documents and reports as requested by the TMD, TPM, or hospital administration.
• Assist the TPM with external education.
• Assists with preparation for American College of Surgeons site surveys.
• Assists with maintaining Trauma policies and procedures.
• Coordinates and participates in trauma performance improvement/patient safety forums/committees.
• Through the use of the trauma registry and peer review information, provide 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.
• Participate in the Trauma Performance Improvement Committee monthly meetings. Providing input to the agenda, records minutes and reports on significant trends, issues and outstanding items.
• Selects and prepares the cases for review for the multidisciplinary peer review meetings in
  
  

collaboration with TMD and TPM.

• Attend and participate in the peer review process and counsel and train members to increase
  
  

awareness of adverse trends and participation in interdisciplinary process improvement.

• Identify areas for improvement and education, using trauma PI data to develop educational
  
  

programs in conjunction with trauma outreach/educational coordinator to address quality issues identified in the trauma program.

• Regionally and internally collaborate, consult, with individuals/departments/committees to
  
  

coordinate and implement the yearly requirements for trauma performance improvement/patient safety.

• Serves as a resource/mentor to others in the area of trauma PI and registry.
• Instructs others on pertinent standards and guidelines and ensures that these standards and guidelines are adhered to.
• Establish channels of communication and reporting which encourage interdisciplinary cooperation, respect, and support among members of the trauma service and the personnel with which they come in contact.
• Facilitate the development of and/or creation of clinical management guideline surveillance, variance and reporting in conjunction with the Trauma Peer Review and/or Program Performance Committee.
• Coordinates follow-up back to facilities that transfer patients into the trauma center and to
  
  

institutions to which trauma centers utilize for transfer.

• Serves as a liaison and collaborates with all departments involved in the care of trauma patients.
• Serves as an active member of trauma specific committees and is an active participant in strategic planning for the Trauma Program.
• Lead injury prevention and bicycle safety initiatives within the community.
• Attends outside conferences and meetings pertinent to job responsibilities.
• Assist in other job duties as requested per TPM.
• Challenges current working practices; identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization’s culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.
• Performs other related duties as assigned.
• Graduate of an accredited School of Nursing.
• Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts.  
• Basic Life Support and ACLS Certification required and must maintain certifications. 
• PALS certification required within 6 months of hire and must maintain certification.
• Stop the Bleed certification required within 3 months of hire and must maintain certification.
• Attend/Schedule TOPICS course within 3 months of hire.
• TNCC certification preferred. 
• 3-5 years’ experience working in a Trauma environment caring for trauma patients in an Emergency Department, Critical Care or other acute care setting.
• Experience in Process Improvement preferred.
  
  

Purpose of Position

Assists the Trauma Program Medical Director (TMD) and the Trauma Program Manager (TPM) to improve the quality of trauma care throughout the continuum of care. Collaborates with the TMD and the TPM to study, plan, implement and evaluate trauma care to assure adherence to the Trauma Program’s Performance Improvement/Patient Safety (PIPS) program through clinical review both concurrent and retrospective and chart review of trauma patients. The TMD will be ultimately responsible for the PI facilitated by the PIPS Coordinator. Effective continuous performance improvement and patient safety programs depend upon concurrent monitoring of the events surrounding the care and outcome of injured patients. Rational decision-making aimed at improving trauma care must be based upon a detailed understanding of the causes, treatment, and outcomes of injury.

Schedule Details

Full-Time, Mon-Fri, Occ Evenings

Organization

Cape Cod Hospital

Primary Location

Massachusetts-Hyannis

Department

CCH-Trauma

Employee Classification

Regular-Regular

Shift

Day/Eve

Weekend Shifts

None

Holiday Shifts

None

Posting Start Date

Oct 24, 2023

Posting End Date

Ongoing