Start the day excited to make a difference...end the day knowing you did. Come join our team.

Essential Functions & Responsibilities:

• Maintains and coordinates the Trauma PI program to ensure adequate documentation as required by Virginia Office of Emergency Medical Services (VA OEMS) in collaboration with the Trauma Medical Director, the Trauma Program Manager, the Trauma Performance Improvement Specialist, and Trauma Injury Prevention Programs.
• Assists with Performance Improvement activities, including planning, developing, organizing, and evaluating of the Mary Washington Hospital, Trauma Performance Improvement and Patient Safety (PIPS) Program.
• Supports the written MWH Trauma PIPS plan. This will include development of quality indicators, complications, and other tracking/trending.
• Coordinates performance improvement aspects of the adult trauma program with appropriate departments, managers, staff, and physicians
• Ensures that MWH maintains Commonwealth of Virginia verified, Level II Trauma Standards regarding performance improvement and other related standards.
• Participates in the monthly interprofessional Trauma PIPS Committee. Shares appropriate data and documents information for the peer review protected minutes.
• Documents all performance improvement activities from weekly Trauma Review, daily chart review, peer review presentation, follow up and loop closure. May include use of MWH quality documentation tools such as the A3 or Focus PDCA.
• Maintains secure and confidential documentation of all PIPS activities, including files, minutes, and loop closure.
• Ensures all PIPS documents interface with the trauma registry.
• Incorporates pre-hospital and referring hospitals in the PIPS plan.
• Works with registry staff to develop and execute queries from the registry, using standard query tools.
• Collects data from internal and external sources to be used for benchmarking. Maintains, tracks, and shares data as needed.
• Participates in an annual review of applicable trauma registry inclusion criteria.
• Supports regional, state, and national trauma performance improvements activities.
• Participates the in Trauma Quality Improvement Program (TQIP) activities.
• Oversees the outcome letter process to pre-hospital providers and referring hospitals partners to provide performance improvement feedback and insight.
• Performs other duties as assigned.

Qualifications:

• Valid RN License from Virginia or reciprocal compact state required.
• Bachelor's degree preferred.
• Three (3) years of trauma care (Floor, ED, Critical Care, trauma program) required.
• Knowledge of Trauma Registries, E-codes, ICD10-CM and PCS coding, ISS coding and AIS coding preferred.
• Certification in Lean, Six Sigma, and/or project management preferred.
• Computer skills in word processing, spreadsheets, data analysis, project management, presentations and internet research preferred.
• Excellent written and verbal communication and presentation skills preferred.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.