Trauma Performance Improvement Nurse, *Sign-On Bonus Eligible*

University of California - San Francisco; Oakland (CA); On-site; USD 120,000 - 150,000; Full time

Job summary

The Trauma Performance Improvement Nurse at University of California, San Francisco works to sustain the hospital’s designation as a Level I Pediatric Trauma Center, ensuring ACS standards, aiding verification, and contributing to trauma registries to benchmark performance, support research, and drive system-wide improvement.

The role involves establishing and supervising PI processes, evaluating practice against outcomes and cost-benefit, and supporting planning and continuous quality

Qualifications

• Minimum 5 years experience as a Registered Nurse in a pediatric acute care hospital (Trauma/ED/CC preferred).
• Bachelor’s degree in nursing or healthcare profession, or equivalent education/experience.
• In-depth knowledge of quality improvement standards, chart review/abstraction, regulatory requirements.
• Knowledge of QI models, data collection/abstraction, validation, analysis, reporting, and performance indicators.
• Familiarity with Alameda County trauma center designation requirements and ACS Trauma Verification standards.

Responsibilities

• Trauma registry management, data analysis and reporting, and coordination of PI activities.
• Oversight of injury prevention and community outreach initiatives.
• Collaborate with leadership, clinical departments, ACS, and EMS to advance trauma care quality.

Skills

Pediatric nursing

Quality improvement

Data analysis

Trauma registry

AIS/ISS coding

EMR reporting

Regulatory knowledge

Project management

Leadership

Education

Bachelor’s degree in nursing

Master’s degree in health sciences

Tools

Trauma Registry software

ICD-10 coding

Job description

Overview

The Trauma Performance Improvement Nurse supports and sustains the hospital’s designation as a Level I Pediatric Trauma Center. The program ensures compliance with ACS standards, assists in trauma center verification, and contributes to trauma registries to benchmark performance, support research, and drive system-wide improvement. The role involves establishing and supervising processes (e.g., performance improvement, clinical documentation) to achieve excellence in trauma services, evaluating practice within patient outcomes, cost-benefit, and access to care, and supporting strategic planning and continuous quality improvement programs. The Nurse applies extensive knowledge of quality data analysis and improvement methodologies on large-scale projects and participates in PI evaluation, review, and solution implementation to optimize trauma care. Additionally, trained in Trauma Registry, the role maintains and assures the quality and accuracy of the trauma registry database, supports standard work, data entry, and timely reporting for regional and national partners. The program collaborates with hospital leadership, clinical departments, ACS, and EMS authorities to advance trauma care quality and public health/safety.

Key Responsibilities

• Trauma registry management, data analysis and reporting, and coordination of performance improvement activities.
• Oversight of injury prevention and community outreach initiatives.
• Collaborate with hospital leadership, clinical departments, the ACS, and regional EMS authorities to advance trauma care quality.

Required Qualifications

• Minimum 5 years experience working as a Registered Nurse in a pediatric acute care hospital (Trauma, ED, and/or critical care preferred).
• Bachelor’s degree in nursing or other healthcare profession, or a combination of comparable clinical education and/or experience (e.g., Master’s degree in health sciences, advanced practice, CNS).
• In-depth knowledge of quality improvement standards, clinical chart review and abstraction, and regulatory requirements.
• In-depth knowledge of QI models, tools, data collection/abstraction, validation, analysis, reporting, and use of performance/benchmark indicators.
• Knowledge of Alameda County trauma center designation requirements and American College of Surgeons Trauma Verification standards (may be learned within 3 months of hire).
• Experience with Abbreviated Injury Scoring (AIS), Injury Severity Scoring (ISS); Trauma Registry experience preferred; completion of Trauma Registry course (within 1 year of hire); ICD-10 coding training.
• Advanced organizational and project management skills; ability to lead a team, prioritize tasks, and complete projects on schedule.
• Advanced interpersonal skills for collaborating with clinical/technical staff and external regulatory agencies; mentoring of junior QI staff.
• Strong ability to convey complex clinical and technical information in writing and presentations; ability to generate reports from trauma registry and other data sources (e.g., EMR).
• Broad knowledge of pathophysiology and medical terminology; ability to abstract/review data for compliance with standards.
• Current knowledge of national/regional trauma registry practices; willingness to learn and share knowledge (may be learned within 6 months of hire).
• Active pursuit of current evidence and resources to support clinical care improvements (networking with internal/external resources, e.g., TQIP).
• Knowledge of applicable standards, procedures, protocols, and guidelines; ability to identify gaps and support updating standards to current evidence-based practice.

Preferred Qualifications

• Post-graduate degree in health sciences preferred.
• Certified Specialist in Trauma Registry (CSTR); may be completed within one year of hire.
• Certified Abbreviated Injury Scale Specialist (CAISS).
• LEAN training/certification (or similar Quality Methodology).
• TNCC preferred (current certification).
• Advanced critical thinking and problem solving to manage multiple levels of highly complex information and responsibilities.
• Advanced knowledge of administrative/quality data management software and tools.
• Strong ability to influence and persuade staff and clinicians across departments.

License/Certification

• Current California Registered Nurse licensure.
• Current American Heart Association BLS certification.
• AAAM AIS Coding Course completion and American Trauma Society Registrar Basic/advanced course completion (may complete within 1 year of hire).
• ICD-10 Course Certificate (current within past 5 years); may be completed within 1 year of hire.