Trauma Performance Improvement and Patient Safety Coordinator

JFK Memorial Hospital has provided medical care to residents in the Coachella Valley since 1966. A group of physicians, including Dr. Reynaldo Carreon, founded the hospital and today one of JFK’s cross streets is named in his honor.

GENERAL DUTIES:

The Trauma Performance Improvement and Patient Safety (PIPS) Coordinator works in conjunction with the Trauma Program Manager (TPM and Trauma Medical Director (TMD) in monitoring all aspects of care and reports primarily to the Trauma Program Manager.

1.The Trauma Performance Improvement and Patient Safety Coordinator, in conjunction with the Trauma Administrative Team, monitors guidline compliance, identifies opportunities for improvement and manages the performance improvement program.

2. The Trauma Performance Improvement and Patient Safety Coordinator is responsible for: Meeting Riverside County Trauma Center Standards as well as JC and American College of Surgeons (ACS) standards, complying with all state and federal regulations, complying with corporate and hospital policy and procedures, managing patient information, promoting teamwork and positive customer service
3. Is actively involved, cross trained and able to perform back up in the following duties:
i. Attends hospital, Tenet, Medical Staff, Department meetings as assigned by the Director of Emergency Services or the TPM.
ii. Meet hospital wide and department specific competencies.
iii. Participates willingly in Department/Hospital process improvement plans.
iv. Ensures confidentiality with patient and physician information and demonstrates understanding of HIPAA.

DEPARTMENT SPECIFIC DUTIES:

• Maintain participation in a state or national clinical organization pertaining to trauma registry.
• Able to demonstrate proficiency with computer hardware, trauma registry software and ensuring preventative and routine maintenance for a database registry.
• Accurately identifies all patients for entry into the hospital trauma registry, abstract data from the medical records of appropriately defined trauma patients.
• Completes and verifies for accuracy all data collected and entered as a requirement for a level III trauma center according to current local, state and national standards.
• Aids in the preparation for the ACS Committee on Trauma - (ACS-COT) on Trauma Level III Trauma Center Verification/Re-verification and/or the Riverside County EMS Agency (REMSA) trauma survey.
• Analyzes trauma data to provide both routine and AdHoc reports of trauma statistics and performance improvement and patient safety audits/filters to the TPM for but not limited to:
  • monthly performance improvement meetings and trauma operational meetings, routine volume reporting, statistics, trends in audit filters, loop closure evaluation and opportunities for improvement, education, financial analysis, trauma audit committee and southeast trauma coordinating care committee, external oversight: The Joint Commission, CMS, and the ACS-COT, and/or REMSA, Trauma research.
• Assigns and scores all injuries utilizing the AIS and ICD-10 system or equivalent. Assigns accurate E-codes, collects and codes data on all procedures, complications, ensures all data elements for the hospital trauma registry are collected, entered and validated per current local, state, and/or national standards.
• Develops and reports trauma audit filter information to the Trauma Operational Committee and Trauma PI Committee as appropriate.
• Ensures loop closure on all identified issues.
• Maintains confidentiality of patient care and business matters.
• Monitors the security of data to ensure the integrity and reliability of database systems.
• Performs chart reviews for those trauma patients meeting criteria for PI/Peer Review
• Prepares the cases for review for the multidisciplinary peer review meetings.
• Proven ability to abstract data from database software into spreadsheet formats.
• Responsible for maintaining the tracking system for case review, audit filters, PI, and peer review reports.
• Submits the required data elements to the Riverside County trauma registry as required by state statute. Identifies and submits data to approved local, regional, and national trauma registry as approved by the TPM.
• Attends required orientation, training, and continuing education seminars.
• Demonstrates initiative and creativity in problem solving.

POSITION QUALIFICATIONS:

Required:

• Licensure/ Certification/ Registration:
  • Current California RN license
  • Current American Heart Association, BLS, ACLS, and PALS
• Education: Bachelor's Degree required
• Experience: Minimum of three years of trauma nursing experience or equivalent.
• Ability to create and make data presentations to groups with varied needs.
• Proficiency with Microsoft Office: Windows, Power Point, Excel
• Skills Knowledge: Ability to think proactively; act creatively, critical-thinking, excellent interpersonal skills.
• Demonstrated ability to work as part of multiple teams and in diverse cultural community groups.
• Advanced Trauma Care for Nurses (ATCN) within 18 months
• TOPIC Course within 6 months of hire
• TCAR within 12 months of hire

Preferred:

• Master’s Degree
• Trauma Certified Registered Nurse (TCRN) Certification
• Knowledge of trauma statistical reports, peer review, performance improvement and epidemiology.
• Experience in public speaking, demonstrates excellence in verbal and written communications

Schedule: Monday thru Friday. 8:00am - 4:30pm

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Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.