Job Summary
Position is responsible for coordinating and facilitating the Trauma Performance Improvement Patient Safety process by interfacing with all hospital departments that participate in the care of the traumatically injured patient. This position also supports and ensures compliance with the Texas Department of State Health Services (DSHS) and/or the American College of Surgeons (ACS) standards and typically reports to the Trauma Program Manager/Director at the facility level.
Job DescriptionMinimum Qualifications
Education: Bachelors Degree in Nursing, Master’s Degree preferred
Licenses/Certifications: Registered Nurse, TOPIC Course completion required within 12 months from date of hire
Experience / Knowledge / Skills:
- Five (5) years clinical experience in either emergency department or a critical care area within a designated/verified trauma center
- Three (3) years experience implementing performance improvement process/initiatives with DSHS and/or ACS, Joint Commission standards, or regulatory agencies (Including National Trauma Data Bank-NTDB)
- Effective oral and written communication skills while maintaining patient confidentiality
- Demonstrates proficiency in word processing, development of spreadsheets, data reporting, and statistical analysis
- Demonstrates the ability to critically think and perform chart abstraction
Principal Accountabilities
- Serves as a Trauma Performance Improvement subject matter expert and provides consultation and support to hospital leadership, Trauma Program Manager and/or Director and facility
- Participates in Regional, State, or National trauma committees
- Coordinates the Trauma Performance Improvement Program at the facility level to include data collection, collation, analysis, modification, and instruction.
- Reviews Performance Improvement indicators and medical records for accuracy, completeness of documentation, and audit filters as specified by the DSHS or the ACS.
- Collects and analyzes benchmarking data, focus studies and clinical indicators.
- Provides education, ensures loop closure, prepares reports, presents outcomes and participates in continuous improvement projects as it relates to the trauma program.
- Organizes and coordinates new employee trauma education and orientation to facility charting and trauma care expectations
- Monitors compliance with established standards as set forth by the policy and procedures of the trauma program; as well as, national, state, and regional agencies.
- Documents performance improvement processes to determine success of actions and implementations of loop closure/resolution/next steps.
- Provides patient follow-up with physicians, hospitals, and emergency medical services.
- Interprets and presents data that supports process improvement and research by identifying variations in patient care delivery and measuring outcomes with benchmarks.
- Reports any identified quality of care concerns including sentinel events, deaths, transfers, or complications.
- Collaborates with the trauma team to prepare documents for trauma medical peer/case reviews, morbidity and mortality, or other meetings as requested.
- Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
- Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.
- All other duties as assigned.
