Trauma Quality Improvement Coordinator

City/State

Work Shift

• →Coordinates and supports the trauma program Performance Improvement and Patient Safety (PIPS) program.
• →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.
• →Monitors compliance with trauma clinical guidelines, protocols, and pathways.
• →Collaborates with trauma registrars to ensure accurate case abstraction and data validation.
• →Assists with preparation and submission of TQIP and state trauma registry data.
• →Develops reports and dashboards highlighting key trauma quality metrics.
• →Prepares cases for Trauma Performance Improvement Committee meetings.
• →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
• →Assists with 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.
• →Provides education and guidance to trauma registrars.
• →Supports development of trauma clinical practice guidelines and protocols.
• →Promotes a culture of safety, transparency, and continuous improvement across the trauma program.

• 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