Job Objective:  

Under the direction of the Trauma Program Manager (TPM) or designee, the Trauma Performance Improvement (PI) Coordinator supports the needs and operations of the Trauma Program. The PI Coordinator is responsible for oversight and coordination of quality and performance needs of the Trauma Service. The PI Coordinator works closely with the Trauma Quality Specialists for collection, abstraction and coding of trauma patient data to ensure compliance with all rules and regulations of the Trauma Registry.  

Duties and Responsibilities: 

1. Oversight and Coordination 

1. Conducts concurrent review of patients within the program throughout their Medical Center stay, reviewing plan of care for compliance with standards and clinical practice guidelines 

1. Identifies variations or gaps in care and communicates deficiencies to involved care providers to ensure compliance with standards 

1. Reviews medical records and other source documents to collect clinical data of patients in the Trauma Program according to the specifications and guidelines of the applicable data element. Any fall outs must be discussed with the TPM and respective unit leaders 

1. Keeps TPM informed of patient status and reports any unusual or trending variances to support active and timely performance improvement. Assists the TPM with concurrent review and the coordination patient care within the program as necessary. 

1. Uses trauma registry, Medical Center event reporting systems, multi-disciplinary rounds, and other relevant data to identify opportunities for improvement 

1. Reviews trauma audit filters, outcomes and benchmark reports to ensure adequate documentation is performed as required by the Los Angeles County Department of Health Services and the American College of Surgeons Committee on Trauma (ACS-COT) 

1. Coordinates trauma PI projects  

1. Establishes practice management guidelines 

1. Prepares report presentation and peer review cases  

1. Assists the Trauma Quality Specialists with complex chart reviews to ensure accurate capture of diagnosis, procedures and complications are identified  

1. Collaborates with the TPM and Trauma Medical Director in the review and analysis of benchmark reports 

1. Collaborates with the TPM to assure the Trauma Performance Improvement Patient Safety (PIPS) program is driven by Trauma Registry data based on National Trauma Data Standards and Los Angeles County Department of Health Services data requirements 

1. Identifies quality improvement issues in the clinical setting 

1. Attends trauma related meetings 

1. Coordinates trauma care management within the multidisciplinary team 

1. Collection and Tracking Patient Data 

1. Assists with collection of trauma data and entry into the Trauma Registry to include data required by regulatory agencies and data used for internal program monitoring and process improvement 

1. Participates in data analysis and processes to ensure data validity and integrity 

1. Responsible to remain up-to-date with data definitions as related to abstraction of the data. 

1. Assist and Support Routine and Special Functions 

1. Works collaboratively with team members as required during review of the medical record 

1. Review any potential fall outs with identified staff and provide education 

1. Collaborates with the Trauma Medical Director and Trauma Program Manager in carrying out the clinical and educational activities of the Trauma Program 

1. Completes required continuous training and education, including department specific requirements  

1. Regulatory Duties  

1. Collects data required for clinical reports for the Medical Center , County, Emergency Medical Services and the State 

1. Facilitates maintenance of licensure and accreditation standards among the multidisciplinary team for Trauma Center Verification 

1. Facilitates compliance with regulatory agency standards, i.e. CMS, CDPH, Joint Commission, OSHA and other regulatory/accreditation organization 

1. Education  

1. Continuously stays abreast of the most contemporary standards in trauma care science 

1. Applies recent trauma Care science and systems innovations to the evaluation and improvement of Antelope Valley Medical Center (AVMC) Trauma Program 

1. Works with all clinical educators and Nursing Education division on continuing education for trauma staff across the continuum to ensure proficiency and competence 

1. Provides education and support for patient and families by giving them written educational materials and facilitating family conferences with members of the Trauma Team 

Non-Essential Duties: 

• Clerical support such as phones, filing, and other duties as needed 

Knowledge, Skills and Abilities:  

Knowledge  

• Advanced knowledge of trauma care 

• Knowledge of state and federal regulations relating to the trauma department 

Skills 

• Strong organizational skills, interpersonal skills, and communication skills 

• Demonstrated leadership skills 

• Strong analysis and problem solving skills 

• Computer skills to include data entry and basic knowledge of MS Office Professional (Outlook, Access, Excel, PowerPoint, and Word). 

Abilities  

• Critical thinking and problem solving abilities 

• Ability to organize information, people, and resources 

• Ability to function independently with minimal supervision 

• Ability to work collaboratively with and through others 

• Ability to handle diverse responsibilities concurrently 

• Ability to train employees and families 

AVMC Values: All AVMC employees will effectively demonstrate these values: 

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority. 

• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us. 

• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone.  Success is about the whole team. 

• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking. 

• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality. 

• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value. 

• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other. 

AVMC Conduct/Compliance Expectations: 

• Ability to adhere with AVMC Attendance and Punctuality Policy   

• Ability to adhere with AVMC Leaves of Absence Policy 

• Ability to adhere with AVMC Paid Time Off (PTO) Policy 

• Ability to adhere to the department dress code 

• Ability to organize work and establish priorities  

• Ability to expand on own initiative in performance of duties 

• Skill and ability to follow the telephone etiquette/standards  

• Ability to function effectively under pressure and meet time parameters 

• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff 

• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC 

• Ability to maintain the confidentiality of patient, hospital and department information  

• Ability to adhere to safety rules and regulations 

• Safely and effectively uses all equipment necessary to carry out duties  

• Ability to interpret and function under hospital and department policies and procedures 

• Conforms with required and appropriate accreditation and regulatory requirements 

• Conforms with and supports hospital quality assurance and improvement guidelines 

• Ability to participate effectively in department and hospital staff education  

• Display a willingness to work as a team player 

• Ability to give and support the highest level of patient/customer satisfaction at all times  

• Supports and adheres to the values and mission statement established by the AVMC Board of Directors 

• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies. 

• Ability to follow the Code of Conduct  

Physical Requirements and Working Conditions: 

• Activities are performed in an environmentally controlled environment subject to long periods of sitting and working with a computer and occasional standing and walking 

• Regular exposure to biological products, including blood, urine, and fixed tissue samples 

• Regularly required to bend, stoop, reach, sit, lift, and carry up to 20 pounds.  

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.