Trauma Quality Improvement Coordinator

Overview

Sentara Health is seeking to hire a qualified individual to join their team as a Trauma Quality Improvement Coordinator. The position is full-time (40 hours a week), dayshift, with standard working hours of 8:00AM - 5:00PM during training. Flexibility with working hours will be provided after successful completion of training.

Essential Duties & Responsibilities

• Captures and supports the trauma program’s performance improvement and patient safety processes in accordance with American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) standards, state trauma regulations, and organizational quality initiatives.
• Identifies cases for review using audit filters, registry data, complications, and mortality reviews.
• Facilitates timely case reviews with trauma leadership and multidisciplinary teams.
• Tracks and documents quality issues, opportunities for improvement (OFIs), and corrective actions.
• Ensures loop closure for identified performance improvement events.
• Maintains documentation required for ACS trauma center verification and site visits.
• Reviews trauma registry data and quality reports to identify trends and performance gaps.
• Maintains compliance with trauma clinical guidelines, protocols, and pathways.
• Collaborates with trauma registrars to ensure accurate case abstraction and data validation.
• Aids in the preparation and submission of TQIP and state trauma registry data.
• Develops reports and dashboards highlighting key trauma quality metrics.
• Coordinates multidisciplinary case reviews, including participation from trauma surgery, emergency medicine, nursing, radiology, and other specialties.
• Documents committee discussions, recommendations, and action plans.
• Supports implementation of system improvements and education initiatives based on case review findings.
• Ensures trauma PI processes comply with: American College of Surgeons (ACS) Trauma Center Standards, State trauma system requirements, Hospital quality and patient safety policies.
• Aids in the preparation for State & ACS trauma center verification and re-verification visits.
• Maintains documentation of PI activities, meeting minutes, and loop closure evidence.
• Provides education to trauma staff regarding quality improvement findings and best practices.
• Supports development of trauma clinical practice guidelines and protocols.
• Promotes a culture of safety, transparency, and continuous improvement across the trauma program.

Qualifications

• Bachelor's of Science in Nursing required.
• RN Licensure - VA/Compact required.
• Minimum 3 years of clinical ED or ICU, preferably trauma-related, experience.
• Experience with quality improvement, patient safety, or trauma registry preferred.
• Knowledge of ACS trauma verification standards and PIPS processes.
• Knowledge of Excel and EPIC.