Trauma Center Quality Program Manager

UMass Memorial Health Care Published: June 21, 2018
Job Type


The Quality Program Manager, Trauma Program will be accountable to strengthen the Trauma Center’s Performance Improvement and Patient Safety, by developing programs that are focused on education, outreach, and clinical research activities. S/he oversees and is accountable for ensuring collection, maintenance, analysis, and dissemination of quality, safety, research and compliance data findings.  The Quality Program Manager must also be able to design, manage and implement a variety of projects and improvement activities across multiple academic and operational departments.  S/he will be directing and /or collaborating with a diverse range of internal and external contacts, ranging from pre-hospital providers, patients/families, care improvement consultants, nurses, surgeons, and other care providers and multidisciplinary specialists, as well as medical directors.  The Program Manager is supervised by the Manager, Trauma Program and Trauma Medical Director.

PRINCIPAL DUTIES AND RESPONSIBILITIES: Indicate key areas of responsibility, major job duties, special projects and key objectives for this position.  These items should be evaluated throughout the year and included in the written annual evaluation.

Job Responsibilities

Performance Improvement and Patient Safety activities:

  1. Works closely with the Manager, Trauma Program and Trauma Medical Director to identify and develop programs to address opportunities for improvement, assessing clinical care, providing ongoing resource/education for process improvement, monitor and facilitate compliance with pertinent regulatory standards.
  2. Is the content expert on improvement methodologies related to the Trauma patient population and imparts knowledge of improvement process to team leaders and the team.
  3. Assists the team leaders in identifying barriers to implementing improvement plans and developing strategies to overcome these barriers.
  4. Develops the analytic and measurement strategy for all assigned projects including the identification of key metrics necessary for identifying the impact of change on processes of care to ensure ongoing success with improvement strategies.
  5. Leads the coordination and facilitation of performance improvement data collection, analysis, trending and benchmarking of data and outcomes.
  6. Fosters clinical inquiry that includes journal article reviews; presentations; and the development of Evidence-based or Clinical practice guidelines for the trauma patient populations.
  7. Acquires and maintains a current knowledge of the evidence-based practice for discrete populations, such as trauma.
  8. Regularly attends the monthly Trauma Performance Improvement Committee Meeting, Trauma ED Operations Meeting, and the weekly Trauma M & M meeting, as well as preparation of confidential cases for the Trauma Peer Review Committee.
  9. Regularly attends relevant Trauma Services meetings to provide recommendations based on data collection and professional input.
  10. Leads the development and review of patient care policies and nursing and practice standards associated with projects for the service line.

Education/Outreach Activities:

  1. Collaborates with staff educators in developing and supporting clinical nursing practice and innovation in the care of trauma patients.
  2. Fosters clinical practice development through observation, conceptualization, and analysis of complex clinical problems related to trauma and injury with outputs that are as specific as evidence-based in-services, clinical practice guidelines, and trauma nursing grand rounds.
  3. Assists educators in the development of competency standards specific to the population.
  4. Promotes education via lectures, in-services, abstracts, and presentations at local and national meetings as requested.
  5. Works closely with the program team, at times as the lead, on trauma-related education and programming for physicians, nurses, and pre-hospital providers. Current examples include ATLS and TNCC.
  6. Develops, implements and manages trauma-related outreach network for referral hospitals, pre-hospital, fire and police providers. Examples such as trauma case presentation, and external specialty networks.
  7. Monitors the effectiveness of the system of care for all trauma patients with a special emphasis on safe transitions for inter-and intra-facility transfers.

Research Activities:

  1. Works closely with Manager, Trauma Program and Trauma Medical Director to promote quality outcomes through the identification of clinical topics and patient care issues in need of scientific inquiry. Examples include: identification and early intervention for elderly patients experiencing cervical spine injury; determining the effectiveness of non-invasive modalities in the management of pain for patients with multiple rib fractures.
  2. Fosters research activities related to assuring optimal outcomes for the trauma population as principal investigator or co-investigator. These activities may include study conceptualization, design, and implementation of related research activities carried out within the trauma program and in collaboration with members of the multidisciplinary team.
  3. Analyzes and interprets clinical data in conjunction with co-investigators, statisticians, and other members of the research team as appropriate.
  4. Monitors the progress of research activities; develops and maintains records of research activities, and prepares periodic reports as required in preparation for site visits by the American College of Surgeons, as well as for investigators, administrators, funding agencies, and /or regulatory bodies.
  5. Ensures the smooth and efficient day-to-day operation of research and data collection activities, such as IRB documentation including approvals, revision, and renewals.
  6. Collaborates in the preparation of manuscripts for publication.

Additional Activities:

  1. Collaborates with the Manager, Trauma Program and Trauma Medical Director regarding clinical and administrative activities necessary to ensure successful verification by the American College of Surgeons for Level 1 Trauma. May be asked to assume lead roles in selected components of the verification process.
  2. Supports the development of program-based injury prevention activities with analyses of commonly applied datasets, such as trauma, state or MA Department of Public Health, and nationally based (National Trauma Data Bank, as an example).
  3. Demonstrates leadership through promotion of caring practice, systems thinking, and responsiveness to diversity.

Standard Staffing Level Responsibilities: 

  1. Complies with established departmental policies, procedures and objectives.
  2. Attends variety of meetings, conferences, seminars as required or directed.
  3. Demonstrates use of Quality Improvement in daily operations.
  4. Complies with all health and safety regulations and requirements.
  5. Respects diverse views and approaches, and contributes in maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors.
  6. Maintains, regular, reliable, and predictable attendance.
  7. Performs other similar and related duties a

Job Requirements


  1. Master’s degree in Nursing required.
  2. Current Massachusetts RN licensure required
  3. TNCC certification required.


  1. TNCC instructor.
  2. ATLS certification.


  1. 10 years’ experience in health care and/or public health.
  2. Database management and analysis experience.
  3. Experience in health care and patient safety quality measurement, reporting, and improvement
  4. Previous leadership or project management experience, including statistical concepts and applications
  5. Experience working in a large and complex health care organization
  6. Competence with MS Word, Excel and PowerPoint, with ability to utilize spreadsheet and graphic programs to produce bar graphs and charts, are required for this position.
  7. Superior organizational and interpersonal skills with ability to work independently
  8. Demonstrated effectiveness as a team member, team facilitator, and team leader
  9. Ability to manage time and resources effectively to meet project deadlines
  10. Ability to work independently and manage concurrent, time-sensitive projects is essential
  11. Comfortable interacting with a vast array of administrative and interdisciplinary clinical staff, ranging from the Executive Directors of Quality to frontline care providers
  12. High degree of professionalism, discretion, and confidentiality
  13. Thorough knowledge of federal and institutional policies governing clinical research
  14. Occasional early or late meetings and weekend meetings to accommodate clinician and community stakeholders’ schedules
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