POSITION SUMMARY

The Trauma Performance Improvement Coordinator (PIC) works in collaboration with Trauma Medical Director (TMD) and the Trauma Program Manager (TPM) to improve the quality of trauma care encompassing all areas and disciplines of the hospital that participate in the management of the injured patient. The Trauma PIC is responsible for coordination and facilitation of the multidisciplinary trauma performance improvement program including data collection, analysis, trending and benchmarking of data and outcomes while maintaining confidentiality.

Principal Duties:

1. Collaborates closely with trauma program leadership to ensure compliance with the Code of Maryland Regulations (COMAR) for trauma, the Maryland Institute for Emergency Medical Services Systems

a. (MIEMSS) standards, and Prince George's Hospital Center's (PGHC) standards related to Performance Improvement.

2. Coordinates the Multidisciplinary Trauma Performance Improvement/Patient Safety Program in collaboration with TMD and TPM.

3. Implements and sustains the institutional Trauma Multidisciplinary Performance Improvement Plan that meets all regulatory requirements.

4. Facilitates the identification, validation, and documentation of trauma specific performance improvement variances, complications, and quality filters as required by MIEMSS and selected

a. American College of Surgeons (ACS) and National Trauma Data Bank (NTDB) performance improvement variances and complications.

5. Makes clinical rounds with the Trauma team and performs comprehensive, concurrent chart review to identify adverse events, variances in clinical management and outcomes, and institutional system or process issues that negatively impact the care of trauma patients.

6. Assists in the development of both clinical and operational performance indicators.

7. Supports the integrated program for multidisciplinary trauma peer review, morbidity and mortality review, outcomes analysis and reporting.

8. Attends trauma related meetings and prepares peer review cases for appropriate venue.

9. Maintains knowledge of and participates on hospital committees and initiatives related to quality.

10. Maintains secure and confidential documentation of all PI activities, including patient performance improvement files, minutes of peer review and process improvement meetings using standard format.

11. Maintains concurrent case review summaries and a tracking system for trends, follow-up and loop closure.

12. Performs open chart reviews and aggregates data in compliance with documentation standards/best practice.

13. Proficient in data analysis of trauma program studies, including clinical, quality, administrative, epidemiologic, research, and prevention.

14. Through the use of trauma registry, peer review information, and other relevant databases, provides a standardized set of analytical, statistical and reporting strategies for a variety of patients or provider outcomes, to be reviewed by internal and external review committees.

15. Establish channels of communication and reporting which encourage interdisciplinary cooperation, respect, and support among members of the trauma service and the personnel with which they come in contact.

16. Participates in local, regional, state and national organizations to expand knowledge and program development.

17. Demonstrates/verifies proficient use of the current ICD coding and the AIS and ISS injury scoring systems.

18. Designs reports that accurately represent information in the context provided.

19. Submits monthly reports in a concise organized manner.

20. Utilizes computer based reporting mechanisms to abstract and compile reports

21. Translates clinical documentation into data elements for the purpose of driving quality improvement in all areas of clinical quality.

22. Performs data abstraction, criteria-specific or focused chart review, from the medical record as required by The Joint Commission, Center for Medicare Services and other regulatory agencies.

23. Serves as a resource/mentor to others in the area of trauma registry/performance improvement.

24. Performs related work as assigned.

Customer Service:

1. Greets customers in courteous, friendly, respectful and professional manner at all times, including maintaining eye contact when appropriate.

2. Follows communication protocols to both internal and external customers, including introducing him/herself with job title and experience, asking open ended questions, such as "How may I be of help to you?" using the customer's name as soon as it is learned.

3. Responds promptly and appropriately to customer questions/concerns/complaints and attempts immediate resolution.

4. Keeps customer's information confidential, including public places such as elevators or the cafeteria.

5. Provides assistance and offers help immediately, including finding someone else to meet the request, if unable to do so him/herself. Introduce other staff to customers when a hand-off occurs and explain that the person will provide excellent service.

6. Demonstrates commitment to excellent service recovery when a customer's expectations have not been met.

Commitment to Co-Workers:

1. Offers assistance to colleagues and other departments when needed.

2. Takes responsibility for solving problems regardless of origin; completes assignments, and respects deadlines.

3. Resolves conflict directly with colleagues and seeks assistance from others if the issue cannot be resolved. Refrains from criticism in public.

4. Mindful and respectful of others' time and schedules. Attends meetings on time and communicates any absences.

5. Provides co-workers with a status report for continuity of workflow when planning to be out of the office, off the unit, or away from the department

Communication Etiquette:

1. Respectful, courteous and professional in all forms of communication and follows facility's service communication protocol in all interactions.

2. Refrains from use of personal cell phone in patient care areas and keeps usage to a minimum at all other times while on duty.

3. Does not text or use e-mail during meetings (except for exigent or emergency situations).

4. Limits use of business cell phone during meetings (remain on vibrate and/or calls go to voicemail).

5. Makes every effort to answer telephone calls within three rings, introducing him/herself, department and title (if appropriate). Asks permission before placing the caller on hold or using the speakerphone. If caller is transferred, gives the caller the extension number of the person he or she is being transferred to. Offers further assistance to the caller upon completing the conversation.

6. Maintains an appropriate voicemail message and when away from the office has an out-of-office email message that is brief, current, and includes name and department and offers the caller options if possible.

7. Returns email and voicemail messages promptly but no later than within one business day (24 hours).

8. Always mindful of voice and language in public.

Self Management:

1. Reports to work appropriately groomed and in compliance with the Hospital's dress code. Wears identification badge at all times at chest level and facing outwards so identification is clearly visible.

2. Complete all assignments within deadlines or negotiates alternative actions and time frames in order to achieve desired outcomes.

3. Completes mandatory, annual education and competency requirements.

4. Follows UMCAP safety, infection control and employee health standards.

5. Demonstrates responsibility for personal growth, development and professional knowledge and competency.

6. Adhere to all UMCAP and department policies and procedures, including Code of Conduct and professional behavior standards. Does not exceed Hospital guidelines in reference to attendance, punctuality, and use of sick and unplanned absences. Provides notification of absences, lateness and vacation requests according to department guidelines. Respects length of time for lunch and break times.

7. Reviews, signs, and adheres to UMCAP and/or departmental confidentiality statement.