Trauma Performance Improvement & Pt. Safety Coord.

Hennepin Healthcare
July 7, 2020
Minneapolis, MN
Job Type


The Trauma Performance Improvement & Patient Safety (PIPS) Coordinator is fundamental to the development, implementation and evaluation of the trauma program. Working in conjunction with the Adult Trauma Medical Director, Pediatric Trauma Medical Director, Trauma Program Manager and Pediatric Trauma & Critical Care Coordinator, this person initiates, manages and oversees the organization of the Trauma PIPS Program. This individual works with other members of the trauma program to identify areas in need of improvement for the injured patients of all ages, from pediatrics to geriatrics

Job Responsibilities

  • Facilitates and coordinates performance improvement (PI) activities between all departments involved in the management of trauma patients
  • Ensures that all admitted trauma patients have some level of PI review
  • Actively assists in the identification of any care, safety, process or systems issues that have potential performance improvement opportunities
  • Assists with the collection of complication data on trauma patients for the Trauma Registry
  • Prepares case summaries on trauma patients who have had complications and/or died
  • Facilitates the review process, assists in the development of the action plan, method of monitoring, re-evaluation, and benchmarking as appropriate
  • Assists in assuring loop closure in cases that had opportunities for improvement
  • Participates in the development and monitoring of policies, procedures and standards of care
  • Attends and participates in activities of the Adult and Pediatric Multidisciplinary Committees, Concurrent Trauma PIPS Committee and Surgery Morbidity and Mortality Conference
  • Monitors for potential sentinel events as related to the trauma patient
  • Assists in the development of quality review filters
  • Performs audits and case reviews to identify trends and quality care issues
  • Participates in root cause analysis and system reviews conducted on trauma patients as appropriate
  • Incorporates TQIP risk-adjusted benchmarking and outcome reports in analyzing comparative institutional results as related to patient care and system development
  • Works collaboratively to integrate the efforts of the Trauma PIPS Program into the overall Performance Improvement and Patient Safety efforts of the hospital
  • Participates in research projects as appropriate
  • Assists in compliance with NTDB and MN Trauma State System standards
  • Assists in preparation for American College of Surgeons verification site visits
  • Assists in data validation with trauma registry staff as needed
  • Serves as a clinical resource for registry staff

Job Requirements

Minimum Qualifications:

  • Bachelor’s degree in nursing
  • 3-5 years of experience in specified acute care clinical area, e.g.,  trauma, surgical, orthopaedic, stroke, etc

Preferred Qualifications:

  • Master’s degree in nursing
  • 2-4 years of experience in project management, program planning or administration

Knowledge/ Skills/ Abilities:

  • Effective interpersonal communication skills
  • Comprehensive approach with attention to detail in work style
  • Competent in general computer skills and software programs such as Microsoft Word, Excel and PowerPoint preferred
  • Ability to run basic data reports (preferred)
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