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Senior Quality Improvement Specialist - Trauma Services

Mercy

Godfrey, IL

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JOB DETAILS
SKILLS
Accredited Business Accountants (ABA), Analysis Skills, Auditing, Benchmarking, Communication Skills, Corrective Action, Critical Care, Cross-Functional, Data Analysis, Data Management, Data Quality, Documentation, Emergency Care, External Audit, Healthcare, Identify Issues, Internal Audit, Leadership, Mentoring, Nursing, Organizational Skills, Patient Care, Patient Safety, Performance Management, Performance Reviews, Problem Solving Skills, Process Improvement, Quality Management, Registered Nurse (RN), Regulations, Regulatory Compliance, Regulatory Requirements, Reporting Dashboards, Reporting Skills, Risk, Time Tracking, Training/Teaching, Trauma-Neuro Intensive Care (TNCC), Trend Analysis
LOCATION
Godfrey, IL
POSTED
1 day ago

Find your calling at Mercy!

Serves as a Trauma Performance Improvement (PI) Nurse responsible for coordinating the Trauma Performance Improvement and Patient Safety (PIPS) program for trauma and burn patient populations. This role ensures systematic event identification, multidisciplinary review, and documentation of performance improvement activities, including evidence of loop closure, corrective actions, and sustained improvement in alignment with ACS Trauma Center and ABA Burn Center verification standards.

Position Details:

Key Responsibilities:

Trauma Performance Improvement (PIPS) Coordination

  • Coordinate the Trauma Performance Improvement and Patient Safety (PIPS) program for trauma and burn patient populations
  • Organize and facilitate the multidisciplinary review process, including case identification, preparation, tracking, and follow-up
  • Collaborate with Trauma Program leadership, Trauma Medical Director, Burn Medical Director, and multidisciplinary teams to support program goals and regulatory compliance

Event Identification & Audit Filter Management

  • Identify trauma and burn performance improvement events from a variety of sources, including registry data, audit filters, incident reports, peer review, and staff/provider referrals
  • Ensure effective use, review, and ongoing evaluation of trauma and burn audit filters in alignment with verification standards
  • Support development and refinement of audit filters based on trends and program needs

Documentation & Regulatory Compliance

  • Maintain accurate, complete, and survey-ready documentation demonstrating:
    • Event identification and screening processes
    • Effective use of audit filters
    • Multidisciplinary review and case progression
    • Loop closure with documented resolution
    • Corrective actions and follow-up
    • Strategies for sustained improvement over time
  • Ensure all PI activities meet trauma and burn program regulatory requirements
  • Support preparation for site visits, PRQ submission, and internal/external audits

Performance Improvement & Loop Closure

  • Facilitate development and implementation of corrective action plans in collaboration with physicians, nursing, and ancillary departments
  • Demonstrate loop closure by validating that identified issues have been addressed and resolved
  • Monitor outcomes over time to ensure sustained performance improvement and prevent recurrence
  • Escalate high-risk or system-level issues as appropriate

Data Management, Analysis & Reporting

  • Collaborate with trauma registry staff to ensure data integrity, completeness, and alignment with PI activities
  • Track, trend, and analyze PI events and audit filter data to identify opportunities for improvement
  • Develop reports, dashboards, and summaries reflecting trauma PI activity, trends, and outcomes
  • Apply evidence-based practice standards and benchmark comparisons to support recommendations

Education, Collaboration & Program Support

  • Educate and mentor staff and team members on trauma PI processes, including audit filters, case review, and loop closure
  • Promote a non-punitive, systems-focused approach to performance improvement
  • Support ongoing education and process improvement initiatives related to trauma and burn care
  • Collaborate with stakeholders to drive process improvement and sustain outcomes

Additional Job Description:

                Minimum Qualifications

  • Current Registered Nurse (RN) licensure
  • 5 years of related experience (Trauma, Emergency, Critical care, or Burn care)
  • Strong analytical, organizational, and communication skills


 

Preferred Qualifications

  • Knowledge of Trauma PIPS processes and regulatory standards (ACS, ABA, MO state) strongly preferred
  • EPIC and ESO experience preferred
  • TNCC Instructor preferred

Why Mercy?

From day one, Mercy offers outstanding benefits - including medical, dental, and vision coverage, paid time off, tuition support, and matched retirement plans for team members working 32+ hours per pay period.

Join a caring, collaborative team where your voice matters. At Mercy, you'll help shape the future of healthcare through innovation, technology, and compassion. As we grow, you'll grow with us.

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About the Company

M

Mercy

Our Mercy health system was founded by the Sisters of Mercy in 1986. But our heritage goes back more than 185 years. It began with an Irish woman named Catherine McAuley, who wanted to help the poor women and children of Dublin. Though Catherine had a modest upbringing, she received an unexpected inheritance that allowed her to fulfill her dreams. In 1827, she opened the first House of Mercy in Dublin, intending to teach skills to poor women and educate children. Many volunteers came to help. A few years later, Catherine founded the Sisters of Mercy, the first religious order not bound to the rules of the cloister, whose Sisters were free to walk among the poor and visit them in their homes. By the time Catherine died in 1841, there were convents in Ireland and England, and in 1843, the Sisters of Mercy came to the United States. In 1871, they traveled to St. Louis and from there throughout the Midwest, beginning what would, today be known as Mercy.

Mercy, named one of the top five large U.S. health systems in 2018, 2017 and 2016 by IBM Watson Health, serves millions annually. Mercy includes more than 40 acute care and specialty (heart, children’s, orthopedic and rehab) hospitals, 800 physician practices and outpatient facilities, 44,000 co-workers and 2,100 Mercy Clinic physicians in Arkansas, Kansas, Missouri and Oklahoma. Mercy also has clinics, outpatient services and outreach ministries in Arkansas, Louisiana, Mississippi and Texas. In addition, Mercy's IT division, Mercy Technology Services, supply chain organization, ROi, and Mercy Virtual commercially serve providers and patients in more than 20 states coast to coast.

COMPANY SIZE
10,000 employees or more
INDUSTRY
Healthcare Services
FOUNDED
1986
WEBSITE
https://www.mercy.net/