Trauma Program Manager

Antelope Valley Hospital
June 29, 2019
Lancaster, CA
Job Type


The Trauma Program Manager assumes 24-hour responsibility for the planning, development, facilitation, implementation, monitoring, evaluation and continuous improvement of the Trauma Program at Antelope Valley Hospital.

Job Responsibilities

A. Oversees and coordinates quality improvement activities, policies and protocols related to Trauma.

  1. Coordinates and monitors trauma care management across the continuum of care.
  2. Collaborates with the Trauma Program medical director in carrying out the educational, clinical, research, administrative and outreach activities of the trauma program.
  3. Collaborates and develops appropriate required clinical reports for the Hospital, County, Emergency Medical Services and State.
  4. Serves as a liaison between trauma staff and administration.
  5. Develops, implements and evaluates long- and short-term goals for the Trauma Service
  6. Ensures Trauma Service compliance with regulatory agency standards, i.e. Joint Commission, CMS and OSHA
  7. Responsible for collection and maintenance of all data related to Trauma Services and develops processes for validating data, assessing trends and sentinel events.
  8. Liaison and consultant for multidisciplinary teams related to trauma.
  9. Acts as the hospital's point of contact for the American College of Surgeons and Los Angeles County EMS related to designation and verification issues.
  10. Applies recent Trauma Care Science and Systems Innovations to the evaluation and improvement of AVH Trauma Program.
  11. Works with all clinical educators and Nursing Education division on the development and continuing education for Trauma staff across the continuum to ensure proficiency and competence.
  12. Provides education and support for patients and families by giving them written and verbal education materials and by facilitating family conferences with members of the Trauma Team

B. Leadership and Management

  1. Develops and implements Program Goals and Objectives with input from staff members and other hospital departments.
  2. Interacts with all customers to ensure prompt and accurate communication, as needed, to provide the service expected, and to meet the goals of the service.
  3. Evaluates problems and develops and implements solutions.
  4. Develops new ideas and/or systems with innovation and creativity.
  5. Challenges the status quo in looking for more efficient practices.
  6. Leads by example and serves as a professional role model.
  7. Updates employees on present, as well as future changes.
  8. Actively listens and tries to understand before responding.
  9. Shapes an environment that is psychologically safe, encouraging, and nonjudgmental.
  10. Supports, encourages, and contributes to the professional growth of all department employees.
  11. Understands, teaches and implements elements of empowerment and team building.
  12. Adheres to all Compliance & Integrity Program rules and requirements.

C. Human Resource Management

  1. Conforms to Affirmative Action guidelines.
  2. Recognizes, appreciates and capitalizes upon the differences people bring to the job
  3. Sees diversity as an advantage.
  4. Selects staff that will represent the values and maintain the Customer Services Expectation and Standards of the hospital.
  5. Develops and implements job descriptions and performance standards.
  6. Evaluates staff performance, per established policy, including the use of staff competence and quality improvement data.
  7. Mediates personnel problems and resolves complaints using good problem solving techniques.
  8. Conforms to the hospital Wage and Salary Administration and Recording of Hours Worked policies.
  9. Ensures that staff is in compliance with licensure and other annually mandated requirements.

D. Information Systems Management

  1. Understands departmental information systems and other equipment as necessary.
  2. Understands advanced aspects of various information systems.
  3. Understands and conforms to the hospital Information Technology solutions Group strategic plan.

E. Competence

  1. Maintains an appropriate level of professional competence by ongoing development of knowledge and skills.
  2. Performs professional duties in accordance with relevant laws, regulations and technical standards.
  3. Prepares complete, clear reports and recommendation after appropriate analyses of relevant and reliable information.

F. Confidentiality

  1. Refrains from disclosing confidential information acquired in the course of work, except when authorized and unless legally obligated to do so.
  2. Refrains from using or appearing to use confidential information acquired in the course of work for unethical or illegal advantage either personally or through third parties.
  3. Follow Administrative policies on Confidentiality and Privacy Practices.
  4. Informs subordinates, as appropriate, regarding the confidentiality of information acquired in the course of their work and monitors their activities to assure the maintenance of confidential information.

G. Integrity

  1. Regularly demonstrates commitment to a set of ethics and values by behaving in an ethical manner that is consistent with the hospital's mission, vision and values.
  2. Avoids actual or apparent conflicts of interest and advises all appropriate parties of any potential conflict.
  3. Refrains from engaging in any activity that would prejudice the ability to carry out one's duties in an ethical manner.
  4. Refuses any gift, favor or hospitality that would influence or would appear to influence one's actions.
  5. Recognizes and communicates professional limitations or other constraints that would preclude responsible judgment or successful performance of an activity.
  6. Communicates unfavorable as well as favorable information and professional judgment or opinions in a professional manner.
  7. Fully discloses relevant information that could reasonably be expected to influence intended users' understanding of any reports, comments, and/or recommendations presented.


Non-Essential Duties:

  • Participate in the daily duties of all areas of the Trauma Services workload, as needed.
  • Other duties as assigned, within skill sets and abilities.

Accepts and carries out all other miscellaneous clerical and/or administrative duties and responsibilities as required for maintaining all services provided by Antelope Valley Hospital.

Job Requirements


  • Demonstrates knowledge or administrative and human resources policies and procedures, and understands correct labor relations management.
  • Continuous, contemporary knowledge of the most current standards and developments in Trauma Care Science and Systems. Skills
  • Strong organizational skills, interpersonal skills and communication skills are essential.
  • Proven leadership skillsAbilities
  • Individual must possess the ability to be self-directed and function autonomously.
  • Ability to work collaboratively in a self-directed work team environment.
  • Ability to handle diverse responsibilities concurrently.
  • Ability to give and support the highest level of customer satisfaction at all times.
  • Ability to adhere to the Courtesy and Conduct policy.
  • Ability to conform to Joint Commission, CMS and Title 22 requirements.
  • Ability to conform with and support the hospital performance improvement and risk management plans and policies.
  • Ability to support and adhere to the mission, vision and values statements established by the hospital.


AVH Values: All AVH employees will effectively demonstrate these values:

  • Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
  • Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
  • Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone.  Success is about the whole team.
  • Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
  • Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
  • Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
  • Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.


Management Competencies:  All AVH management (Supervisor, Manager, and Assistant Director) will effectively demonstrate these behaviors:

Conflict Management

Problem Solving

Timely Decision Making

Process Management

Fairness to Direct Reports

Hiring & Staffing

Developing Direct Reports


Education and Experience:


  • Bachelors of Science in Nursing preferred.
  • TNCC, TCAR certification preferred.Experience
  • Two (2) years’ ER, ICU, or Trauma experience.


Required Licensure and/or Certifications:

  • Current California Registered Nursing license
  • BLS
  • ACLS
  • PALS (within 6 months of hire or first available Antelope Valley Hospital course).
  • Nonviolent Crisis Intervention Certification, initial certification required at first available hospital training class. Annual recertification required.
  • Annual Restraint Certification/Recertification.
  • Annual JCAHO Review/Competencies.


AVH Conduct/Compliance Expectations:

  • Ability to adhere with AVH Leaves of Absence Policy
  • Ability to adhere with AVH Paid Time Off (PTO) Policy
  • Ability to adhere with AVH Recording of Hours Worked Policy
  • Ability to adhere to the department dress code
  • Ability to organize work and establish priorities
  • Ability to expand on own initiative in performance of duties
  • Skill and ability to follow the telephone etiquette/standards
  • Conforms to AVH Standards of Excellence
  • Ability to function effectively under pressure and meet time parameters
  • Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff
  • Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVH
  • Ability to maintain the confidentiality of patient, hospital and department information
  • Ability to adhere to safety rules and regulations
  • Safely and effectively uses all equipment necessary to carry out duties
  • Ability to interpret and function under hospital and department policies and procedures
  • Conforms with required and appropriate Joint Commission requirements
  • Conforms with and supports hospital quality assurance and improvement guidelines
  • Ability to participate effectively in department and hospital staff education
  • Display a willingness to work as a team player
  • Ability to give and support the highest level of patient/customer satisfaction at all times
  • Supports and adheres to the values and mission statement established by the AVH Board of Directors
  • Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
  • Ability to follow the Code of Conduct

Physical Requirements and Working Conditions:

  • Work is performed in a high stress office environment with frequent staff, patient and physician interaction
  • Accepts additional workload during times of unexpected circumstances, e.g. high activity, high census, surge and sudden emergencies
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