Coordinator, Trauma Quality & Performance Improvement - UH Trauma Services

USA Health is transforming medicine along the Gulf Coast to care for the unique needs of our community. We are changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provides the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve health and overall well-being.

Responsibilities

• Abides by and enforces all compliance requirements and policies, performing responsibilities in an ethical manner consistent with the organization's values.
• Adheres to hospital policies including confidentiality.
• Works the assigned schedule and overtime as needed.
• Enhances professional growth and development through participation in education programs.
• Engages and fosters relationships with all levels of staff within the organization, building strong relationships with team members, faculty, and customers.
• Possesses superior time management skills with the ability to multi-task, prioritize, establish timelines, and meet deadlines.
• Ensures on-time completion of deliverables; highly organized and skilled at managing numerous details for multiple projects.
• Showcases an open mind and spirit to continuous learning and research.
• Practices innovation in process improvement and exhibits passion for harm prevention and evidence-based practice.
• Maintains a spirit of optimism and conviction to speak up for quality and safety, showcasing constructive approaches to errors and system improvement opportunities.
• Advocates for the engagement of the family and patient.
• Communicates and demonstrates appropriate customer relation skills with physicians, patients, families, and co-workers.
• Maintains accurate, complete, and confidential information utilized in the hospital Quality Assurance and Performance Improvement program.
• Serves as a leader or member of various committees.
• Advises organizational leaders and department heads in planning, monitoring, and evaluation activities.
• Applies knowledge of performance improvement tools to assist teams, helping to manage and propel team communications.
• Provides education/information on Performance Improvement activities to various healthcare audiences on a regular basis.
• Serves as a subject matter expert in the concepts of quality management, performance improvement, and patient/family engagement.
• Possesses ability to accurately process detail-oriented work with advanced problem-solving skills, ability to think quickly and implement plans/structure for accomplishing work, remaining composed under pressure, working in a small, fast-moving, and at times, intense environment.
• Anticipates team needs and takes initiative to complete work before being asked.
• Applies strategic planning to address large-scale opportunities for improvement with transformational leadership.
• Evaluates and analyzes complex data using statistical analysis to identify opportunities for improvement.
• Understands the principles of human factors and safety and applies them in performance improvement project designs.
• Participates in root cause and system analysis of sentinel, adverse, or near-miss occurrences to discern improvement opportunities, as needed.
• Coordinates and promotes initiatives in alignment with the Joint Commission National Patient Safety Goals, reduction or elimination of patient harm, and evidence-based quality initiatives.
• Assists the organization in identifying opportunities for improvement.
• Identifies opportunities for improvement in documentation and initiates improvement strategies.
• Develops staff education related to quality and performance improvement initiatives.
• Recommends and uses effective methods to spread quality management and improvement knowledge materials/concepts, meaningful and relevant for organizational needs.
• Plans, collects, organizes, and reports QA data for use in the PI program and in external and internal benchmarking programs according to the hospital’s PI Plan.
• Prepares reports, attends, and presents committee meeting materials.
• Coordinates and/or revises policies and procedures related to evidence-based compliance.
• Facilitates PI activities.
• Collaborates with clinical areas to ensure that care meets evidence-based standards.
• Designs and facilitates revisions or builds in Cerner applications to support evidence-based care.
• Participates in local, state, and/or national activities pertaining to evidence-based care.
• Abstracts and enters data into web-based software for the quality measures.
• Validates data in the various programs as needed.
• Facilitates and participates in activities to ensure that policies/measures and safe practices are being followed.
• Conducts inter-rater reliability audits for the program as indicated.
• Conducts Plan-Do-Study-Act (PDSA) cycles for small, rapid-cycle tests of change.
• Leads performance improvement teams with the science of improvement concepts including lean principles.
• Seeks engagement of all staff, medical staff, and residents in performance improvement initiatives.
• Maintains current knowledge of Joint Commission/CMS standards and regulatory requirements.
• Collaborates in the development of departmental and organizational PI dashboards.
• Communicates relevant aspects of evidence-based standards and compliance to members of the healthcare team and medical staff committees.
• Demonstrates excellent interpersonal verbal and writing skills.
• Maintains accurate and complete records through documentation.
• Uses advanced skills and working knowledge of Microsoft Word, Excel, and PowerPoint.
• Uses internet, email, databases, spreadsheets, word processing, and presentation programs.
• Accepts and completes all duties positively and without conflict.
• Cooperates, helps others, and improves the performance of the department.
• Completes all mandatory unit, educational, and hospital requirements.
• Utilizes cost-effective practices in performing all aspects of the job.
• Coordinates Trauma Performance Improvement and Patient Safety (PIPS) activities.
• Manages trauma audit filters, opportunities for improvement, multidisciplinary review, physician peer review, and loop closure.
• Supports mortality review, root cause analyses, and trauma-focused quality initiatives.
• Supports continuous ACS Level I verification readiness.
• Interprets and applies ACS trauma standards.
• Conducts regulatory gap assessments and corrective action monitoring.
• Maintains verification documentation and collaborates on site visit preparation.
• Partners with trauma registry staff to ensure data integrity and validation.
• Analyzes registry, NTDB, TQIP, and internal quality data.
• Develops dashboards, scorecards, executive reports, and physician performance reports.
• Identifies trends and benchmarking opportunities.
• Collaborates with Trauma Medical Director, Trauma Program Manager, physicians, nursing leadership, and multidisciplinary teams.
• Presents findings to committees and executive leadership.
• Provides education on trauma quality initiatives and regulatory standards.
• Leads strategic trauma quality and patient safety projects.
• Completes all mandatory department, educational, and hospital requirements.
• Adheres to current Infection Control and Safety Standards.
• Regular and prompt attendance; ability to work schedule as defined and overtime as required.
• Other duties as assigned.

Requirements

• Bachelor's Degree in nursing from an accredited institution and 5 years of acute care trauma-related nursing experience.
• Master's Degree in nursing preferred.
• Experience in an ACS-verified trauma center preferred.
• Experience with PIPS, NTDB/TQIP benchmarking, trauma registry methodology, regulatory surveys, TNCC, Lean/Six Sigma preferred.
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in accordance with the Nurse Licensure Compact (NLC) for Alabama.
• Comparable combination of education and experience may substitute for the above requirements.

Benefits

Employees must be in a regular position, working 20 hours or more per week (.50 FTE or greater) to qualify for benefits.