Coord,Performance Improvement

Westchester Medical Center; Town of Mount Pleasant (NY); On-site; USD 85,000 - 115,000; Full time

Job summary

Westchester Medical Center seeks a Performance Improvement Coordinator to manage the Trauma Department's PI program, collaborating with the Trauma Medical Director and Manager to drive clinical outcomes.

The role focuses on monitoring performance, data abstraction from records, and ensuring compliance with regulatory standards for a Level I trauma program, with quality improvement embedded across the care continuum.

Qualifications

• Graduation from an accredited school of Nursing is required; BSN preferred.
• Experience in ER or Critical Care trauma environments is expected.
• Strong data analysis and regulatory compliance knowledge.

Responsibilities

• Coordinate the Trauma PI program and collaborate with Trauma leaders.
• Review patient records to ensure protocol compliance across the care continuum.
• Abstract PI/QA data for the Trauma Registry and generate reports.
• Monitor trends, support loop-closure, and drive outcomes improvement.

Skills

Trauma care

Quality improvement

Data abstraction

Regulatory compliance

Team collaboration

Education

BSN

Master's in Nursing (preferred)

Tools

Trauma Registry software

ICD-10 coding tools

MS Excel

Job description

Job Summary:

The Performance Improvement Coordinator manages all aspects of the Trauma Department's Performance Improvement Program. The Performance Improvement Coordinator is responsible for monitoring and evaluating performance for the Trauma Program and works closely with the Trauma Registry to ensure accurate concurrent data collection and identification of performance improvement occurrences. The Performance Improvement Coordinator collaborates with the Trauma Medical Director, Trauma Program Manager, Trauma Registrars and other disciplines to review the performance and safety of the Trauma Program, including coordinating activities to evaluate issues, promote loop closure, and enhance clinical outcomes. The Performance Improvement Coordinator is accountable for meeting regulatory and accrediting standards for performance improvement and patient safety for a Level I trauma program.

Responsibilities:

Coordinates the Trauma Performance Improvement (PI) Program for the hospital in collaboration with the Trauma Medical Director and Trauma Program Manager Assist the Trauma Program Medical Director and the Trauma Program Manager in evaluating the effectiveness of the Trauma Team and the Trauma Program. Review of patient hospital records, beginning with the 911 call, to determine compliance with patient care protocols, policies and procedures throughout the trauma system care continuum. Abstraction of Performance Improvement/Quality Assurance (QA) data from the hospital records as required for entry into the Trauma Registry. Ensures Trauma Department peer review and PI/QA follow-up by Hospital Departments is completed. Prepares and reports Trauma Department PI/QA data for Trauma Department meetings. Participation in analysis of Trauma Department PI/QA data and interpretation of trends. Preparation of Trauma PI/QA data reports for the Trauma Department and Hospital Department committees. Maintenance of the Trauma Department's PI/QA data, peer review results and all follow-up in the Trauma Registry. Accountable for meeting the federal and state regulatory and accrediting standards of performance and patient safety for a Level I trauma program.

Experience:

3-5 years of experience in either ER or Critical Care taking care of trauma patients at a Trauma Center and/or minimum of 2 years of experience as a Trauma Performance Improvement Coordinator.

Education:

Graduation from an accredited school of Nursing required; a bachelor's degree or master's degree in nursing preferred.

Licenses / Certifications:

BLS/ACLS/PALS/ATLS-ATCN training, TCRN, CFRN, CCRN, or CEN preferred.

Other:

Experience and knowledge of Trauma Quality Improvement Program (TQIP). Proven ability to evaluate data and recommend process changes. Knowledge and understanding of ICD 10 and AIS coding. Knowledge and experience with performance improvement processes, evaluation, needs for recommendation, loop closure.