Trauma Performance Improvement Nurse

The BHC Oakland Trauma Program supports and sustains the hospital's designation as a Level I Pediatric Trauma Center, verified by the American College of Surgeons (ACS). The program ensures compliance with ACS standards, facilitates trauma center verification, and contributes to national trauma registries to benchmark performance, support research, and drive system-wide improvement.

Involves the establishment and supervision of processes (e.g., performance improvement, clinical documentation, etc.) to achieve the optimal degree of excellence in the services rendered to every trauma patient. Evaluation of practice operates within the parameters of patient outcome, cost-benefit in care provision, and patient access to the health care delivery system. Provides for internal strategic planning efforts and implementing continuous quality improvement programs.

Applies extensive knowledge of quality data analysis and / or improvement (QI) concepts, methodologies, and data collection and abstraction techniques to substantial projects of large scope and high degrees of complexity.

The Trauma Performance Improvement Nurse is actively engaged in PI evaluation, review, and solution generation/implementation to improve the optimal care of the trauma patient. They are skilled in writing reports and presenting data graphically, both internally and externally, to promote process improvements, improved outcomes and optimal patient care.

Additionally trained in Trauma Registry, the Trauma Performance Improvement Nurse is responsible for maintaining and assuring the quality and accuracy of the trauma registry database, the foundation of the trauma PIPS process. This role contributes to the development of standard work and during the process of trauma registry data entry, reliably identifies cases that warrant review, fully completes data abstraction into the trauma registry database according to Trauma Service standards, trauma leadership needs, existing regulatory requirements and to meet data entry deadlines for the County, NTDB and TQIP. The Registrar collects, analyzes and reports trauma data for quality improvement tracking as assigned, as well as targeting injury research and prevention. This role implements processes to assure accuracy and confidentiality in the handling of all trauma registry related matters.

Key responsibilities include trauma registry management, data analysis and reporting, performance improvement coordination, and oversight of injury prevention and community outreach initiatives. The program collaborates closely with hospital leadership, clinical departments, the ACS, and regional EMS authorities to advance trauma care quality and promote public health and safety.

DUTIES & ESSENTIAL JOB FUNCTIONS

Identify the functions or tasks that employees in the job perform. The essential functions should state the purpose of the work and the results to be accomplished, rather than how the function is performed. Of the tasks listed, what percentage of time is devoted to each? The more time employees spend on a function, the more likely it is that the function is essential. Generally, include those functions that account for 10% or more of the work, i.e., key items that contribute significantly to the achievement of the job. The functions should add up to 100%.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

35

Performance Improvement

Participates in or leads clinical and technical teams on broad-scope projects using advanced QI models to develop new plans, criteria, and benchmarks

* Participates in the preparation and implementation of the department QI plan (a continuous improvement process), inclusive of daily monitoring, evaluation and closure as appropriate or referral to TPM for patient specific and trending PI issues.

* Supports pertinent hospital quality goals and participates in the development and implementation of department objectives to reflect and support goals.

* Participates in QI monitoring of self and peers, notifies appropriate staff of opportunities to improve patient care.

* Participates in the data preparation and coordination of CQI activities as requested, (Trauma M&Ms, Trauma Advisory, HELI, MQIC, Trauma PI Steering etc.)

* Prepares quarterly QI reports as assigned and collaborates to recommend and implement strategies to ensure improvement in patient care.

* Will perform daily clinical rounds/concurrent entry to monitor clinical processes, outcomes, system issues and trends with the use of quality filters, reports, audits and case review related to quality trauma care. Identified issues/trends will be reported to the TPM & TMD.

* Provides follow-up on problems identified though the QI process. Including outreach to pre-hospital and OSH providers to either seek information or provide information pertinent to PI.

Supports clinical areas on data management activities and projects with significant clinical complexity and organizational scope. Develops relevant department and service quality indicators, structures and measures.

30

Trauma Case Review Responsibilities:

Prepares incident reports and conducts QI reviews of highly-complex mortality cases, sentinel events, readmissions, and other cases flagged by screening criteria. Identifies cases that require urgent reviews and collaborates with management as required to develop and implement appropriate responses.

*Attends and co-leads trauma department meetings at 80% compliance.

*Participates in Unit and Hospital QI activities.

* Knowledgeable in trauma specific clinical practice standards; able to apply this knowledge to identify opportunities for improvement.

*Participates in QI monitoring of self and peers (data validation).

*Actively participates with other team members in maintaining the QI plan for Trauma Services.

*Follows NTDB, ACS and department specific Standards, Procedures, Protocols and Guidelines.

*Assures confidentiality in the handling of all trauma registry related matters.

*Reports information/data indicative of immediate patient risk to TPM, TMD or Director of Trauma.

*Actively engages with TQIP staff to maximize the organization's compliance with TQIP

standards and maximize benefit of risk stratified benchmark reporting to support the trauma PIPS process

*Participates in monthly registry meetings for updates, training, and quality/operational

improvement as needed.

*Participates in in-services and continuing education

*Attends the Alameda County EMS-A Trauma Audit Committee (TAC) meetings with active participation when assigned.

*Actively supports risk management activities.

10

Database Management

Oversees or performs timely and accurate submission of clinical care quality and patient safety data to appropriate internal departments and outside agencies

* Maintains and updates the trauma registry database.

* Evaluates all documentation for accuracy and completeness prior to data entry.

* Abstracts and enters data elements on all trauma patients concurrently.

* Maintains data accuracy using a validation process.

* Ensures data is entered in a timely manner; concurrent for admitted patients and within 1 month of discharge for patients sent home from the Emergency Department.

* Implements changes in database in coordination with Alameda County EMS-A, the National Trauma Data Bank (NTDB), and TQIP (Trauma Quality Improvement Program) and Trauma Services leadership.

* Retrieves demographic and financial information through the electronic health record.

* Adheres to inclusion criteria set forth by Alameda County, State of California (CEMSIS) and American College of Surgeons (ACS) NTDB.

* Assures confidentiality of data and abides by HIPPA regulations.

* Complies with standard work instruction for trauma patient identification, data abstraction and entry.

* Participates in validation of data reliability, accuracy, and completeness of database, including PI data

5

Registry Reports:

Analyzes and interprets highly complex data of broad scope, and summarizes statistical findings. Develops corresponding reports, dashboards, presentations, and action plans. Prepares and delivers executive summaries.

Responsible for delivering established reports when requested and make ready for presentation (i.e. graphs) as needed by Trauma Services.

* Provides and utilizes data from the trauma registry to target and monitor PI initiatives focused on efficient high-quality care.

* Generates routine set of reports for monthly committee meetings as assigned.

* Creates "gather reports" at basic and advanced level of report writing.

* Suggests queries and reports when noticing trends in available data.

* Identifies, analyzes and reports trends for PI to Trauma Services management

5

Registry Reviews

Identifies statistical trends, problems, and potential issues in patient care and services. Participates in or leads project teams in clinical departments to investigate, develop and implement corrective plans, and monitor their effectiveness.

Participates in American College of Surgeons (ACS) verification site reviews.

* Demonstrates knowledge of ACS verification requirements.

* Demonstrates knowledge of Alameda County EMS-A trauma center designation criteria.

* Participates in data validation meetings, TQIP meetings, NTDB meetings when requested.

5

Self Development

Researches best practices and develops and implements improvements in the data collection and reporting processes and / or systems.

Assumes responsibility for own development by participating in in-services and continuing education specific to Quality Improvement and Trauma Registry national standards.

* Assess own learning needs and seeks out resources/opportunities for growth.

* Communicates with manager in a timely manner to obtain needed support/leave for education.

* Maintains professional licensure, certification, or registration as required

10

Staff Development

Serves as a technical leader to provide advice and counsel others on highly-complex QI issues of functionality, efficiency, performance improvement, and program development.

* Participates in staff development activities for unit, division, and hospital personnel as it pertains to the care of the trauma patient,

* Shares knowledge, experience, and offers suggestions for improvement to the Trauma Services team.

* Maintains and shares current knowledge regarding the trauma registry inclusive of AIS, ICD and E-coding, and ongoing monitoring for acceptable data abstracting/data entry performance.

* Participates in the development and maintenance of the Registry