Trauma Performance Improvement Coordinator/ RN, Quality Assurance

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Location (Full Address):

601 Elmwood Ave, Rochester, New York, United States of America, 14642

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

500178 Trauma Program

Work Shift:

UR - Day (United States of America)

Range:

UR URCC 214

Compensation Range:

$73,528.00 - $95,586.00

Responsibilities:

The Trauma Performance Improvement (PI) Coordinator is responsible for the coordination, execution, and ongoing development of the trauma performance improvement and patient safety (PIPS) program within the Acute Care Surgery/Trauma Surgery Division within the Department of Surgery. This role ensures continuous monitoring, identification, investigation, and resolution of deviations in care, with a focus on loop closure, regulatory compliance, and optimal patient outcomes. The PI coordinator will serve as Trauma Surgery Division Quality Assurance Liaison to the Department of Surgery and Hospital Quality Office.

Under the direction of the Trauma Medical Director and Trauma Program Manager, the PI Coordinator will work collaboratively with multidisciplinary clinical teams, Hospital Quality Office, and Departmental/Divisional Quality Teams to ensure adherence to standards set forth by the University of Rochester Medical Center, American College of Surgeons, New York State Department of Health, Joint Commission, and other regulatory offices.

ESSENTIAL FUNCTIONS

Trauma Performance Improvement & Patient Safety (PIPS) Program Management

• Coordinate and manage the Trauma PIPS Program in accordance with American College of Surgeons (ACS) Resources for Optimal Care of the Injured Patient 2022 standards and Hospital Quality Office.
• Utilize Trauma Registry and other data sources to identify individual cases requiring further review using audit filters, complications, and event triggers
• Ensure timely case abstraction, review, and escalation as needed.
• Utilize Trauma Registry and other data sources to track and trend audit filters, complications, and event triggers to identify patterns and trends in care delivery.
• Implement data-driven, evidence-based quality initiatives in coordination with Trauma Medical Director and Trauma Program Manager.
• Utilize ACS Trauma Quality Improvement Program (TQIP) benchmarking reports to analyze trauma center outcomes and aid in prioritization of performance improvement activities and projects.
• Monitor effectiveness of quality initiatives and interventions post-implementation and escalate unresolved issues as necessary.
• Work with Trauma Medical Director and Trauma Program Manager to create and implement policies and procedures based on evidence-based, best practice to optimize patient care.
• Serve as Trauma Division Quality Assurance Liaison to Department of Surgery, which will assume the following responsibilities:
  • Oversight and management of RL Solutions for Trauma Surgery Service.
  • Participation in divisional, departmental, and hospital quality committees.
  • Support and participation in divisional, departmental, and hospital quality initiatives.
  • Participation in Root Cause Analysis process.
  • Participation in Joint Commission surveys.

Data Management & Reporting

• Performs meticulous chart review on individual cases to identify any opportunities for improvement to enhance patient outcomes and complete thorough PIPS documentation, including event resolution with loop closure, for all individual case reviews as required by ACS, Department of Surgery, and Hospital Quality Office.
• Maintain PIPS database, quality dashboards, and audits
• Provide routine data reports to Trauma Program leadership, Department of Surgery, and multidisciplinary trauma committees and teams as requested.
• Will maintain ongoing collaboration with Trauma Registrars to define PIPS audit filters, complications, and event triggers to ensure consistent, accurate PIPS data capture within Trauma Registry.
• Maintain required documentation required for ACS trauma verification visit, as directed by the Trauma Medical Director and Trauma Program Manager.
• Support research activities of the Trauma Program by providing access to and assistance with analysis of relevant data, as directed by Trauma Medical Director and Trauma Program Manager.
• Provide routine reports on Trauma Clinical Practice Guideline compliance.

Multidisciplinary Collaboration and Communication

• Facilitate and support PIPS meetings with multidisciplinary teams to identify opportunities for improvement within trauma patient care, processes, and/or systems.
• Lead multidisciplinary teams in implementing PIPS initiatives pertaining to the care of the injured patient, in coordination with Trauma Medical Director and Trauma Program Manager.
• Responsible for creation of agenda and completion of meeting minutes for weekly Mortality and Morbidity (M&M) Meeting.
• Coordinate interdepartmental case reviews and ensure timely response and follow up.
• Provide thorough communication of PIPS findings and follow up actions with all involved multidisciplinary teams.

Trauma Program Activities

• Will represent the Kessler Trauma Program in program, local, regional, state, and national meetings.
• Participate in community outreach and education activities under the direction of the Trauma Medical Director and Trauma Program Manaher.
• In collaboration with Trauma Service Nurse Educator, provide education on PIPS initiatives, trends, and opportunities to providers involved with the care of the injured patient.
• Actively participate in the preparation for and in the site visit for ACS trauma center verification.

MINIMUM EDUCATION & EXPERIENCE

• Bachelor's degree in Nursing and 4 years clinical nursing experience, including 1 year of experience with clinical chart review, monitoring of clinical data and process improvement required
• Or equivalent combination of education and experience
• Clinical experience in perioperative nursing, inpatient surgical unit, or surgical clinic required
• Three (3) years of clinical chart review, performance improvement, and/or data analysis preferred
• Quality improvement or patient safety knowledge and experience preferred
• Performance improvement or quality assurance experience at ACS Level 1 trauma Center preferred
• Five (5) years in clinical nursing in emergency department or inpatient trauma service preferred
• Supervisory/management experience in clinical setting preferred

KNOWLEDGE, SKILLS AND ABILITIES

• Ability to interact with all members of associated team and administrative staff in a professional and courteous manner required
• Detail oriented with strong organizational and prioritization skills and ability to work independently under general guidance required
• Proficiency in Microsoft Office (Word, Excel, PowerPoint, Access), software/web applications, and electronic medical record required
• Statistical knowledge preferred
• Clinical chart review and abstraction experience preferred
• Excellent communication skills to facilitate professional, courteous, and efficient communication with internal and external parties preferred
• Strong data analysis and interpretation skills preferred

LICENSES AND CERTIFICATIONS

• Licensure as Registered Nurse in NYS required
• Clinical Nurse Specialist (CNS) preferred
• Trauma Certified Registered Nurse (TCRN) preferred
• Advanced Trauma Certified Nurse (ATCN) preferred
• Trauma Nursing Core Course (TNCC) preferred
• Certified Emergency Nurse (CEN) preferred
• Critical Care Registered Nurse (CCRN) preferred

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