Trauma Performance Improvement Coordinator/ RN, Quality Assurance

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.

Responsibilities

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; 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; Create and implement policies and procedures based on evidence-based best practice; Serve as Trauma Division Quality Assurance Liaison to Department of Surgery; Oversight and management of RL Solutions for Trauma Surgery Service; Participation in divisional, departmental, and hospital quality committees and initiatives; Participation in Root Cause Analysis process and Joint Commission surveys; Perform meticulous chart review and complete PIPS documentation including loop closure; Maintain PIPS database, quality dashboards, and audits; Provide routine data reports to Trauma Program leadership and multidisciplinary committees; Collaborate with Trauma Registrars to define PIPS audit filters, complications, and event triggers; Maintain documentation for ACS trauma verification visit; Support research activities of the Trauma Program; Provide routine reports on Trauma Clinical Practice Guideline compliance; Facilitate and support PIPS meetings with multidisciplinary teams; Lead multidisciplinary teams in implementing PIPS initiatives; Create agenda and complete minutes for weekly Mortality and Morbidity Meeting; Coordinate interdepartmental case reviews and follow-up; Communicate PIPS findings and follow-up actions; Represent Kessler Trauma Program in program, local, regional, state, and national meetings; Participate in community outreach and education; Provide education on PIPS initiatives to providers; Participate in ACS trauma center verification site visit

Requirements

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; 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; Licensure as Registered Nurse in NYS required

Nice to have

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; 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; 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