Trauma Program Performance Improvement Coordinator

Alameda Health System
August 27, 2019
Oakland, CA
Job Type


Plans, coordinates, and implements trauma program performance improvement activities as required by AHS, County, State, and American College of Surgeons (ACS) standards and requirements for trauma center verification and designation; responsible for implementing the Trauma Program Performance Improvement Plan and monitoring compliance to Trauma Program standards, policies, procedures and practices; supervises Trauma Program employees.

Job Responsibilities

DUTIES & ESSENTIAL JOB FUNCTIONS:  NOTE: The following are the duties performed by employees in this classification.  However, employees may perform other related duties at an equivalent level.  Not all duties listed are necessarily performed by each individual in the classification.

1.  Supervises Trauma Program employees, including counseling, coaching, training and completing performance reviews.

2.  Interprets and applies County, State, and ACS standards of care to contribute to the optimal care of patients.

3.  Oversees all aspects of participation in the ACS Trauma Quality Improvement Program (TQIP).

4.  Designs data collection systems and processes that support the Trauma Program Performance Improvement Plan.

5.  Monitors and measures the quality and timeliness of care provided by physicians, nurses, and other healthcare providers for patients of all ages throughout the continuum of care.

6.  Participates in Trauma Multidisciplinary Rounds to identify, report, and monitor compliance with guidelines and standards of care, complications of care and performance issues.

7.  Maintains reporting database, incorporating the following activities: identifies, tracks, monitors and reports complications and performance trends; analyzes and interprets performance improvement related statistical reports and compiles and reports results; develops and conducts audits with the assistance of the trauma data analyst that supports trauma program performance improvement activities; accesses and interprets clinical data from a variety of databases to review pre-hospital, emergency department, hospital records, and rehabilitation records; works with the Trauma Data Analyst to provide regular reports or as requested by administration or other ancillary departments; monitors trended data for specific complications.

8.  Collaborates with the TMD & TPM on loop closure and maintains required documentation.

9.  Evaluates and reports Trauma Program performance by developing and applying process and outcomes measures.

10. Participates in all phases of planning, preparation, and execution of an ACS trauma center re-verification review and trauma center designation.

11. Acts as a resource to the trauma registrar staff and nursing.

12. Tracks all performance improvement activities, conducts follow-up of open issues, and works with leadership to resolve issues, as required.

13. Prepares case summaries for review by the TMD, TPM, and other PI reviewers.

14. Supports preparation of the Trauma Performance Improvement and Patient Safety Committee agenda, case summaries, and presentation materials.

15. Educates nursing staff in TNCC procedures, trauma nursing documentation and performance improvement content.

16. Performs other duties as required.

Job Requirements


Required Education: Bachelor's degree in Nursing.

Preferred Education: Master's degree in Nursing, Public Health or Informatics.

Required Experience: Five years of trauma nursing experience, within a Critical Care environment, ICU or Emergency Department.

Preferred Experience: Experience within a trauma quality or performance improvement environment; experience utilizing databases, including developing and producing statistical reports; experience implementing or participating in the implementation of evidence-based practice projects; teaching experience.

Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California; Basic Life Support Certification (BLS) issued by the American Heart Association.

Preferred Licenses/Certifications: Emergency Nurses Association Trauma Nurse Core Course (TNCC).

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