Coord,Performance Improvement in Valhalla, New York at Westchester Medical Center

Job Summary: The Performance Improvement Coordinator manages all aspects of the Trauma Department's Performance Improvement Program. The Performance Improvement Coordinator is responsible for monitoring and evaluating performance for the Trauma Program and works closely with the Trauma Registry to ensure accurate concurrent data collection and identification of performance improvement occurrences. The Performance Improvement Coordinator collaborates with the Trauma Medical Director, Trauma Program Manager, Trauma Registrars and other disciplines to review the performance and safety of the Trauma Program, including coordinating activities to evaluate issues, promote loop closure, and enhance clinical outcomes. The Performance Improvement Coordinator is accountable for meeting regulatory and accrediting standards for performance improvement and patient safety for a Level I trauma program.

Responsibilities: Coordinates the Trauma Performance Improvement (PI) Program for the hospital in collaboration with the Trauma Medical Director and Trauma Program Manager

Assist the Trauma Program Medical Director and the Trauma Program Manager in evaluating the effectiveness of the Trauma Team and the Trauma Program.

Review of patient hospital records, beginning with the 911 call, to determine compliance with patient care protocols, policies and procedures throughout the trauma system care continuum.

Abstraction of Performance Improvement/Quality Assurance (QA) data from the hospital records as required for entry into the Trauma Registry. Ensures Trauma Department peer review and PI/QA follow-up by Hospital Departments is completed.

Prepares and reports Trauma Department PI/QA data for Trauma Department meetings.

Participation in analysis of Trauma Department PI/QA data and interpretation of trends.

Preparation of Trauma PI/QA data reports for the Trauma Department and Hospital Department committees.

Maintenance of the Trauma Department's PI/QA data, peer review results and all follow-up in the Trauma Registry.

Accountable for meeting the federal and state regulatory and accrediting standards of performance and patient safety for a Level I trauma program.

Qualifications/Requirements:

Experience: 3–5 years of experience in either ER or Critical Care taking care of trauma patients at a Trauma Center and/or minimum of 2 years of experience as a Trauma Performance Improvement Coordinator.

Education: Graduation from an accredited school of Nursing required; a bachelor’s degree or master's degree in nursing preferred.

Licenses / Certifications: BLS/ACLS/PALS/ATLS-ATCN training, TCRN, CFRN, CCRN, or CEN preferred.

Other: Experience and knowledge of Trauma Quality Improvement Program (TQIP).

Proven ability to evaluate data and recommend process changes. Knowledge and understanding of ICD 10 and AIS coding. Knowledge and experience with performance improvement processes, evaluation, needs for recommendation, loop closure.