Trauma Performance Improvement Specialist

Mary Washington Healthcare; United States; On-site; USD 54,000 - 81,000; Full time

Job summary

Mary Washington Healthcare is seeking a Trauma PI Specialist to coordinate performance improvement and patient safety for Trauma Services, including oversight of the Trauma Registry, data analysis, reporting and trend identification to guide outreach and education.

The role collaborates with the Trauma Program Manager and Trauma Medical Director to ensure program quality and ACS/OT compliance, managing data quality, reporting, and PI initiatives across the Trauma Program.

Qualifications

• Bachelor’s Degree in nursing required; MSN preferred.
• Licensed Registered Nurse by the State of Virginia or compact state required.
• CPR required.
• Three years’ experience in Emergency, Trauma Outreach, Critical Care, education/clinical education, Performance Improvement, or Trauma Registry.
• Knowledge of chart abstraction and trauma registry, reporting, data analysis, trend identification and benchmarking per ACS/OT standards.
• Proficient in data analysis of trauma program studies across clinical, administrative, epidemiologic, and prevention domains.

Responsibilities

• Develop and maintain quality indicators for the trauma program.
• Coordinate activities with Trauma Program Manager and Trauma Medical Director to ensure program quality and standards.
• Execute the Trauma PI Plan to monitor, evaluate, and improve performance.
• Review the PI continuum from prehospital to discharge and ensure compliance with care protocols.
• Maintain verification readiness with ACS/OT and OEMS requirements.
• Oversee data submission to VA OEMS, NTDB, and ACS/COT TQIP.
• Conduct data collection, analysis, and reporting from medical records and other sources.
• Prepare PI reports for committees, identify issues, and drive loop closure.
• Provide trauma program support and liaison for ED, prehospital care, and trauma staff education.

Skills

Data analysis

Trauma registry

Quality improvement

Project coordination

Statistical reporting

Communication

Education

Bachelor’s Degree in Nursing

Licensed Registered Nurse (Virginia or compact state)

MSN

Job description

Job Summary:

The Trauma PI Specialist will serve as the coordinator for performance improvement and patient safety activities for Trauma Services, which includes oversight of the Trauma Registry and Registrars, quality indicators, data analysis, trending, and report preparation to help guide outreach, injury prevention and educational activities based on data.

Essential Functions & Responsibilities

Collaborates with the Trauma Program Manager and Trauma Medical Director to develop and maintain a set of quality indicators for the trauma program to ensure teammates in all departments dealing with the care of the trauma patients are knowledgeable about the Trauma Program and standards of care. Coordinates activities with the Trauma Medical Director and Trauma Program Manager to facilitate overall Trauma Program quality and consistency. Executes the Trauma PI Plan to monitor, evaluate, and improve the performance of the Trauma Program. Reviews the PI continuum of care beginning with the prehospital setting through hospital discharge (which may include multiple inpatient and ancillary units) and determination of compliance with patient care protocols, policies, procedures, and established standards of care. Works with the trauma program leadership to ensure compliance with the regulatory requirements of the American College of Surgeons, Committee on Trauma, and the Virginia Office of Emergency Medical Services Trauma Division to maintain a consistent state of verification readiness. Supervises the validation, preparation, and submission of trauma data to the VA OEMS, National Trauma Data Bank, and ACS, COT Trauma Quality Improvement Program. Manages the Trauma PI database in accordance with ACS and State guidelines. Conducts the collection, surveillance, data entry, analysis and reporting of trauma quality and performance information from medical records as well as other resources. Through the use of the trauma registry, peer review information, and other relevant databases, provides 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. Communicates existing or potential trauma performance improvement issues and opportunities identified in trauma case evaluation and reports trending to the Trauma Program Manager and Trauma Medical Director. Prepares various PI reports for meetings, data analysis, issue identification, and issue resolution, including loop closure. Provides support functions for all aspects of the trauma program. May respond to Trauma Activations during normal working hours to act as a resource person and liaison for the Emergency Department and pre-hospital care providers, including EMT’s, paramedics, and flight crews. Assists the Trauma Program Manager with the development of the Trauma Resource Nurse role as well as the education and implementation of new trauma staff and processes. Coordinates with the Trauma PI Coordinator in the investigation, analysis, and responses to quality/patient safety issues, events, significant care issues, or trends. Provides oversight of the Trauma Registry and Staff to ensure data is accurate and timely. Participates in local, regional, state, and national organizations to expand knowledge and program development. Performs other duties as assigned.

Qualifications

Bachelor’s Degree in nursing required, MSN preferred. Licensed Registered Nurse by the State of Virginia or compact state required. CPR required. TNCC, ENPC, CEN, TCRN preferred. Minimum of three (3) years’ experience in Emergency, Trauma Outreach, Critical Care, education/clinical education, Performance Improvement, or Trauma Registry required. Knowledge of chart abstraction and the trauma registry, including reporting, data analysis, trend identification and benchmarking of outcomes based on the American College of Surgeons, Committee on Trauma standards and recommendations for quality and maintenance for trauma center verification/reverification required. Proficient in data analysis of trauma program studies, including clinical, quality, administrative, epidemiologic, research, and prevention required.

MWHC will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status (EOE). We are also committed to equitable and transparent compensation practices and comply with all applicable pay transparency and pay equity laws.

Required Physical Requirements:

Constant (67-100% of workday) sitting and use of arms and hands; occasional (0-33% of workday) standing, walking, bending, squatting; ability to lift, push, and pull up to 10 lbs.; auditory and visual skills.

Mental Requirements:

Possesses critical thinking and analytical skills. Ability to multi-task. Ability to communicate effectively and collaborate with a multi-disciplinary team.

Environmental Requirements and Exposure Hazards:

Potential risk of exposure to chemicals. "It is the policy of Mary Washington Healthcare to provide reasonable accommodations to qualified individuals with a disability who are applicants for employment or Associates."

Compensation Pay Range

$39.44 - $59.15

Working at Mary Washington Healthcare Whether you are a new grad, experienced clinical professional or wanting to begin a career in healthcare, there is no better place than Mary Washington Healthcare. As a Great Place to Work-Certified company we treat our Associates like family – with respect, understanding, and communication. Safety is our top priority As a healthcare system, patient and Associate safety is our priority which is why all Associates will be required to take the following vaccines*: Annual flu vaccine *MWHC reserves the right to amend this list at any time. Medical and Religious exemptions may apply,. Will be discussed at interview.