DESCRIPTION OF POSITION:
- In all trauma centers with an annual volume that exceeds 1,000 registry patient entries, the trauma center must have at least 1 FTE performance improvement nurse (PI).
- Assists the Trauma Medical Director (TMD) and the Trauma Program Manager (TPM) to improve the quality of trauma care throughout the continuum of care.
- Collaborates with the TMD and TPM to study, plan, implement, and evaluate trauma care to assure adherence to the Trauma Center’s Performance Improvement Program through clinical review, both concurrent and retrospective, and chart review of trauma patients.
- The TMD will ultimately be responsible for the PI facilitation by the PI Nurse. Effective continuous performance improvement and patient safety 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 on injury.
SUPERVISION: Reports directly to the Trauma Program Manager and the Trauma Medical Director
RESPONSIBILITIES AND DUTIES:
- Develops, implements, and revises the Trauma Center Performance Improvement Plan in collaboration with the TMD and TPM. This plan must be reviewed and approved every 3 years, at minimum.
- Responsible for issue identification, issue validation, issue analyses, and initiates follow-up to assure loop closure to improve clinical outcomes and patient care.
- Develops corrective actions and strategies for sustained improvement measured over time
- Reviews all TQIP reports and use the results to determine whether there are opportunities for improvement in patient care and registry data quality
- Conducts patient rounds while utilizing clinical expertise to aggregate, assess, and interpret information in order to evaluate the quality of clinical care, and review of appropriate services.
- Identify areas for improvement and education; using this data to develop educational programs, action plans to address quality issues identified and to ensure follow through of developed plans.
- Oversees the collection, tracking, and benchmarking of trauma PI issues related to patient care and system development.
- Correlates outcomes and PI findings with trauma registry data and adherence to the Trauma Center registry criteria, accuracy, and inter-rater 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.
- Ensures that all pertinent issues are entered into the Trauma Registry as they occur.
- Describes all pertinent details of each issue in an agreed upon format.
- Tracks loop closure/resolution in Trauma Registry.
- Assists the TMD and the TPM to evaluate the effectiveness of the Trauma Team and the Trauma Program.
- Produces and analyzes trended data and provider specific profiles in collaboration with the TPM.
- Assist in the preparation of any documents and reports as requested by the Trauma Medical Director, TPM, or hospital administration
- Assists with preparation for American College of Surgeons site surveys.
- Assists with maintaining Trauma policies and procedures.
- Coordinates and participates in trauma performance improvement/patient safety forums/committees.
- Through the use of the trauma registry 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 Peer Review Committee and Trauma Operations meetings. Provides input to the agenda and reports on significant trends, issues and outstanding items.
- Selects and prepares the cases for review for the multidisciplinary peer review meetings in collaboration with TMD and TPM.
- Attends 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 in conjunction with Trauma Community Outreach Coordinator to address quality issues identified in the trauma program.
- Regionally and internally collaborates with individuals/departments/committees to coordinate and implement the yearly requirements for trauma performance improvement/patient safety.
- 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 into the trauma center and to institutions to which trauma centers utilize for transfer.
- Coordinates follow-up back to EMS agencies who transport trauma patients to the Trauma Center.
- Facilitate the development of and/or creation of clinical management guideline surveillance, variance and reporting in conjunction with the Trauma Peer Review and/or Operations Committee
- Assist in other job duties as requested per TPM.
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
EDUCATION AND WORK EXPERIENCE
- BSN preferred
- 2 years critical care experience required (ED, OR, ICU)
- Current RN license in Louisiana or multi-state compact license
- BLS, ACLS, PALS, and TNCC Required. TCRN preferred.
- Ability to read, write and speak intelligible English; Capable of clear and succinct verbal and written communications
- Possess a high level of patience and tenacity; Capable of rapid problem identification and resolution
Physical Demands/Work Environment
- Work requires a variety of physical activities including standing and walking for long periods of time, bending, stooping, and lifting.
- The work environment may be physically confining.
- Visual acuity is required for a variety of specific activities.
- Must have normal hearing or utilize adaptive hearing devices if duties require listening with a stethoscope to discern breath sounds, heart sounds, and bowel sounds.
- Ability to do shift work as required.
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
“Experience Memorial” is more than a slogan, it’s the care we provide our patients and it’s the commitment to our community and our team members. As a nationally certified Great Place to Work, at Lake Charles Memorial Health System you will have the opportunity to be a part of an organizational culture that supports not only exceptional patient care but also the well-being and professional growth of our employees. Join us and be a part of a team where your contributions are valued, your growth is nurtured, and your success is celebrated.
Working at Lake Charles Memorial Health System | Great Place To Work®