Trauma Performance Improvement Coordinator

The Trauma Performance Improvement Patient Safety Coordinator assists the Trauma Program Medical Director (TPD) and the Trauma Program Manager (TPM) in improving quality of trauma care throughout the continuum. Collaborates with the TPD and the TPM to implement and assure adherence to the Trauma Program’s Performance Improvement Patient Safety Program and the PTSF through concurrent and retrospective clinical and chart review of trauma patients. The work of the Performance Improvement Patient Safety Coordinator will facilitate this process with the Trauma Program Medical Director who will be ultimately responsible for the quality improvement program. Effective continuous quality improvement programs depend upon concurrent monitoring of the events surrounding the care and outcome of injured patients. Rational decision-making aimed at improving trauma care must be based upon a detailed understanding of the causes, treatment, and outcomes of injury.

• Coordinates the Trauma Performance Improvement (PI) Program for the hospital in collaboration with the Trauma Medical Director and Trauma Program Manager.
• Conducts patient rounds to review services and adherence to the PTSF standards. Utilizes clinical expertise to aggregate, assess and interpret information in order to evaluate the quality of clinical care.
• Review patient occurrences, user defined indicators, and audit filters with Trauma registrar and validate data on a concurrent basis.
• Responsible for issue identification, issue validation, issue analyses, and initiates follow-up to assure loop closure that will improve clinical outcomes and patient care.
• Identify areas for improvement and education; using this data to develop educational programs, action plans to address quality issues identified in the trauma program and to ensure follow through on these plans.
• Oversees the collection, tracking and benchmarking of trauma PI issues related to patient care and system development.
• Correlates POPIMS outcomes and PI findings with trauma registry data for adherence to PTOS criteria, accuracy, and inter-relater reliability and educates registry staff as needed to ensure required compliance for trauma center accreditation.
• Provides concurrent feedback and issue resolution to the trauma service and liaisons.
• Maintenance of the Trauma PI database (POPIMS) to ensure adequate documentation as required by Pennsylvania Trauma Systems Foundation (PTSF). Ability to produce clear effective reports and to track issues over time.
• Update POPIMS database on a daily basis using concurrent and retrospective review of patient care.
• Ensure that all pertinent issues are entered into POPIMS as they occur.
• Describe all pertinent details of each issue in an agreed upon format.
• Tracks loop closure/resolution in POPIMS.
• Assist the Trauma Program Medical Director and the Trauma Program Manager to evaluate the effectiveness of the Trauma Team and the Trauma Program.
• Produces and analyzes trended data and provider specific profiles in collaboration with Trauma Program Manager, Trauma Performance Improvement Medical Director.
• Assist in the preparation of any documents and reports as requested by the Pennsylvania Trauma Systems Foundation, Trauma Director, Trauma Program Manager or administration.
• Assist TPM with external education.
• Assists with preparation for PTSF site surveys.
• Assists with maintaining Trauma policies and procedures.
• Coordinates and participates in trauma performance improvement forums/committees.
• Through the use of the trauma registry, POPIMS and peer review information, provide a standardized set of analytical, statistical and reporting strategies for a variety of patients or provider outcomes, to be reviewed by internal and external review committees
• Serves as an active member of trauma specific committees and is an active participant in strategic planning for the Trauma Program.
• Participate in the Trauma Committee Meeting. Report on significant trends, issues and outstanding items.
• Selects and prepares the cases for review for the multidisciplinary peer review meetings in collaboration with TPMD and TPM.
• Attend and participate in the peer review process and counsel and train members to increase awareness of adverse trends and participation in interdisciplinary process improvement.
• Serves as a liaison and collaborates with all departments involved in the care of trauma patients.
• Identify areas for improvement and education, using trauma PI data to develop educational programs to address quality issues identified in the trauma program.
• Regionally and internally collaborate, consult, with individuals/departments/committees to coordinate and implement the yearly requirements for trauma performance improvement.
• Attends outside conferences and meetings pertinent to job responsibilities.
• Serves as a resource/mentor to others in the area of trauma PI and registry.
• Instructs others on pertinent standards and guidelines and ensures that these standards and guidelines are adhered to.
• Establish channels of communication and reporting which encourage interdisciplinary cooperation, respect, and support among members of the trauma service and the personnel with which they come in contact.
• Coordinates follow-up back to facilities that transfer patients to St. Luke’s and to institutions to which we transfer.
• Facilitate the development of and/or create in conjunction with the trauma Peer Review and/or Clinical Management Guideline surveillance, variance analysis and reporting.