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%.

Required Qualifications:

• Minimum 5 years experience working as a Registered Nurse in a pediatric acute care hospital (Trauma, ED, and/or critical care preferred)
• Bachelor's degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience (I.e. Masters degree in a health sciences profession, Advance practice, CNS).
• In-depth knowledge of QI standards, clinical chart review and abstraction, and regulatory requirements.
• In-depth knowledge of QI models, tools, and techniques, including collection, abstraction, validation, analysis, reporting of data, and use of performance and benchmark indicators.
• Demonstrated knowledge with Alameda County trauma center designation requirements, as well as the American College of Surgeons Trauma Verification standards. (May be learned within 3 months of hire).
• Experience with Abbreviated Injury Scoring (AIS), Injury Severity Scoring (ISS) Trauma Registry preferred, completion of Trauma Registry course (May be completed within one year of hire); preferably experience with Lancet Trauma One Registry. ICD -10 coding training.
• Advanced organizational and project management skills, with the ability to lead a team, prioritize tasks, and see projects through from inception to completion on schedule.
• Advanced interpersonal skills for collaborating effectively with all levels of clinical and technical staff and representatives of external regulatory agencies and for mentoring lower-level QI staff.
• Advanced ability to effectively convey complex clinical, technical, and educational information both verbally and in writing, and to produce high quality reports, documentation, and presentations. Ability to generate reports from trauma registry as well as other sources of data ( i.e. EMR, manually captured data).
• Demonstrates breadth and/or depth of knowledge and skills required for position including proficient understanding of pathophysiology and medical terminology. Ability use this knowledge to abstract and review data for clinical compliance with unit and organizational standards
• Maintains current knowledge with national and regional trauma registry requirements and practices; shares technical knowledge. This includes required clinical and database knowledge and skills, as applicable (may be learned within 6 months of hire)
• Actively seeks out current evidence and resources for assistance and direction to facilitate improvement in identified clinical care; this includes networking with internal and external resources (i.e. TQIP).
• Knowledge of Structure Standards, Procedures, Protocols, Guidelines as needed to perform job functions. Ability to identify gaps where standards are needed and support codifying and/or revising standards to remain up to date with current evidence-based practice.

Preferred Qualifications :

• Post-graduate degree in health sciences preferred
• Certified Specialist in Trauma Registry (CSTR); may be completed within one year of hire
• Certified Abbreviated Injury Scale Specialist (CAISS)
• LEAN training/certification (or similar formal Quality Methodology)
• TNCC preferred (current certification)
• Advanced critical thinking and problem solving skills to manage multiple levels of highly-complex information and responsibilities, to quickly assess problems, and to develop and implement timely and effective solutions.
• Advanced knowledge of various administrative and business software packages, and of the specialized applications for quality data management
• Advanced skills to influence and persuade staff, management, and clinicians at all levels and across departments.

License/Certification :

• Current California Registered Nurse licensure
• Current American Heart Association BLS
• AAAM AIS Coding Course completion and American Trauma Society Registrar Basic and/or advanced course completion (may complete within 1 hear of hire)
• ICD-10 Course Certificate (current within the past 5 years); may be completed within 1 year of hire

Required Qualifications:

• Minimum 5 years experience working as a Registered Nurse in a pediatric acute care hospital (Trauma, ED, and/or critical care preferred)
• Bachelor's degree in nursing or other healthcare profession, or a combination of comparable clinical education and / or experience (I.e. Masters degree in a health sciences profession, Advance practice, CNS).
• In-depth knowledge of QI standards, clinical chart review and abstraction, and regulatory requirements.
• In-depth knowledge of QI models, tools, and techniques, including collection, abstraction, validation, analysis, reporting of data, and use of performance and benchmark indicators.
• Demonstrated knowledge with Alameda County trauma center designation requirements, as well as the American College of Surgeons Trauma Verification standards. (May be learned within 3 months of hire).
• Experience with Abbreviated Injury Scoring (AIS), Injury Severity Scoring (ISS) Trauma Registry preferred, completion of Trauma Registry course (May be completed within one year of hire); preferably experience with Lancet Trauma One Registry. ICD -10 coding training.
• Advanced organizational and project management skills, with the ability to lead a team, prioritize tasks, and see projects through from inception to completion on schedule.
• Advanced interpersonal skills for collaborating effectively with all levels of clinical and technical staff and representatives of external regulatory agencies and for mentoring lower-level QI staff.
• Advanced ability to effectively convey complex clinical, technical, and educational information both verbally and in writing, and to produce high quality reports, documentation, and presentations. Ability to generate reports from trauma registry as well as other sources of data ( i.e. EMR, manually captured data).
• Demonstrates breadth and/or depth of knowledge and skills required for position including proficient understanding of pathophysiology and medical terminology. Ability use this knowledge to abstract and review data for clinical compliance with unit and organizational standards
• Maintains current knowledge with national and regional trauma registry requirements and practices; shares technical knowledge. This includes required clinical and database knowledge and skills, as applicable (may be learned within 6 months of hire)
• Actively seeks out current evidence and resources for assistance and direction to facilitate improvement in identified clinical care; this includes networking with internal and external resources (i.e. TQIP).
• Knowledge of Structure Standards, Procedures, Protocols, Guidelines as needed to perform job functions. Ability to identify gaps where standards are needed and support codifying and/or revising standards to remain up to date with current evidence-based practice.

Preferred Qualifications :

• Post-graduate degree in health sciences preferred
• Certified Specialist in Trauma Registry (CSTR); may be completed within one year of hire
• Certified Abbreviated Injury Scale Specialist (CAISS)
• LEAN training/certification (or similar formal Quality Methodology)
• TNCC preferred (current certification)
• Advanced critical thinking and problem solving skills to manage multiple levels of highly-complex information and responsibilities, to quickly assess problems, and to develop and implement timely and effective solutions.
• Advanced knowledge of various administrative and business software packages, and of the specialized applications for quality data management
• Advanced skills to influence and persuade staff, management, and clinicians at all levels and across departments.

License/Certification :

• Current California Registered Nurse licensure
• Current American Heart Association BLS
• AAAM AIS Coding Course completion and American Trauma Society Registrar Basic and/or advanced course completion (may complete within 1 hear of hire)
• ICD-10 Course Certificate (current within the past 5 years); may be completed within 1 year of hire