TRAUMA PERFORMANCE IMPROVEMENT SPECIALIST

TRAUMA PERFORMANCE IMPROVEMENT SPECIALIST 

The Trauma Performance Improvement (PI) Specialist fulfills an essential function and is dedicated to the Trauma Program and Service at Jamaica Hospital Medical Center (JHMC).  In accordance with the American College of Surgeons (ACS) standards for the trauma program selected candidate will work in collaboration with the trauma program leadership and be responsible for the coordination and facilitation of the trauma performance improvement process. The TPIS collects and analyzes benchmarking data, focus studies and clinical indicators. They use advanced skills in quality assessment to perform comprehensive quality of care and service audits to facilitate the development of valid standards and tools. The TPIS ensures loop closure, prepares reports, presents outcomes, and participates in organizational-wide continuous improvement projects as it relates to the trauma program. S/he is self-motivated and a team player. This individual demonstrates accuracy and confidentiality in the handling of all trauma-related matters. Most importantly, the person in this position can conduct quantitative data analysis in reporting (metrics) as well as the qualitative (clinical case review and analysis). The TPIS needs to continually challenge the Trauma Program and Trauma Teams to look at data; drawing them to metrics that measure care and outcomes and driving to results (PDCA) on safety and quality improvement.

Responsibilities

• Implements, coordinates, and sustains the multidisciplinary Performance Improvement/Patient Safety (PIPS) Program in collaboration with the Trauma Medical Director (TMD), Associate Trauma Medical Director (ATMD) and Trauma Program Director (TPD), ensuring the program is able to meet (ACS) Committee on Trauma (COT) Level 1 Trauma Center verification standards.
• Identifies, validates, and documents clinical, operational, and/or systemic variances in the delivery of care to the trauma patient, including reviews, referrals, feedback, and loop closure.
• Performs collection, tracking, and benchmarking of trauma PI data.
• Correlates trauma patient outcomes and PI findings with trauma registry data for adherence to ACS and NYSDOH criteria.
• Tracks and reports significant trends, issues, and outstanding items to the TMD, ATMD, and TPD.
• Aggregates data and prepares reports, graphs, presentations, and documentation for all trauma PIPS meetings, including, but not limited to: Multidisciplinary Peer Review Committee (MPRC), Trauma Operations Performance Improvement Committee (TOPIC), and others.
• Coordinates and schedules monthly trauma MPRC and TOPIC meetings.
• Prepares meeting agendas and presentations for the trauma PIPS committee meetings in conjunction with the TMD, ATMD, and TPD.
• Develops the minutes for the MPRC and TOPIC meetings, with final approval by the TMD, ATMD, and TPD.
• Maintains a trauma PI database to ensure adequate documentation of event identification, validation, review, referral, discussion, event resolution, and loop closure as required to support sustained verification as a Level 1 Trauma Center.
• Produces and analyzes trended data and provider-specific profiles in collaboration with the TMD, ATMD, and TPD.
• Assists in the preparation of any documents and reports as requested by the NYSDOH, TMD, ATMD, TPD, and/or hospital administration.
• Identifies opportunities for improvement and education using trauma registry performance improvement reports and data.
• Defines, develops, and utilizes accepted measures to evaluate quality of care and service utilizing appropriate benchmark comparison and statistical analysis in conjunction with the TMD, ATMD, and TPD.
• Analyzes benchmark reports from the ACS Trauma Quality Improvement Program (TQIP) in collaboration with the TMD, ATMD, and TPD.
• Participates in committee and department meetings, as required, including, but not limited to: MPRC, TOPIC, Prehospital PI committee, and others as designated by the TMD, ATMD, and/or TPD.
• Assists with preparation for site surveys by the ACS, NYSDOH, and any other regulatory agency as required.
• Assists with the development, review, revision, and maintenance of all trauma-related policies and procedures.
• Assists the TMD, ATMD, TPD, Injury Prevention Coordinator, and others with internal and external trauma education.
• Participates in local, regional, state and national organizations to expand knowledge and program development.
• Other and additional duties as assigned.

Professional Development

• Maintain current membership and actively participate in regional or national trauma associations, such as, but not limited to, Society of Trauma Nurses (STN), American Trauma Society (ATS), Emergency Nurses Association (ENA), American Association of Critical Care Nurses (AACN), and EAST (associate member).
• Participate in regional and state trauma advisory committees as directed by the TMD, ATMD, and/or TPD.