Provides primary support to the Trauma Program Director for the trauma performance improvement and patient safety (PIPS) program. The incumbent will be responsible for the maintenance of processes related to multidisciplinary trauma peer review and internal trauma systems issues including case reviews, identification of issues (provider and system), tracking and trending of complications/audit filters/issues to ensure loop closure, and maintenance of appropriate files and data systems. Demonstrates initiative, resourcefulness and problem solving skills. Demonstrates detailed knowledge of American College of Surgeons (ACS) Committee on Trauma requirements, Los Angeles and Orange County trauma requirements, trauma hospital PIPS requirements, the trauma standard of care across the continuum and the operations of the hospital trauma system.
Essential Job Outcomes and Function:
Responsible for all aspects of the trauma performance improvement and patient safety processes including systems and peer review processes. Includes but is not limited to writing care summaries, data abstractions, dvelopment of PI dashboard, and overall process improment plan action items
Identifies cases that require review, peer review, systems review, and reporting to Department of Health
Participates in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) fulfilling all aspects of the TQIP agreement including but not limited to the following: ensuring data submission, review of TQIP data validation reports in collaboration with the Trauma Program Director and Trauma Registrars, completion of the monthly tests, participation in webinars and conferences, and other duties as assigned. Participates in local, regional and national meetings, conferences, trauma PI initiatives
Actively reviews ACS TQIP benchmark reports, identifies areas for improvement, develops and implements of PIPS action plans, and tracks/trends the results to ensure that the desired outcomes are achieved.
As a subject matter expert complete chart reviews, case reviews on deaths, audit critieria, select complications, systems issues, and clinical issues
Responsible for maintaining the tracking system for all cases, case reviews, audit filters, PIPS reports and peer review reports by updating the tracking system using various hospital systems and committees to assure for loop closure in accordance with the American College of Surgeons
Works closely with the trauma program director to ensure timely resolution on identified issues
Works closely with all departments and divisions that interface with the trauma patient to facilitate the PIPS/peer review processes including all aspects of the loop closure process (case review, data review, literature review, root case analysis, ad hoc meetings, development of policies, evidence based practice management guidelines, education, and collaborates with all departments on their implementation and evaluation of corrective actions)
Prepares the cases and meeting packets for the monthly multidisciplinary peer review meeting
Attends and completes minutes for the multidisciplinary peer review meetings
Prepares, reviews, and reports trauma audit information to the Trauma QI Committee and Trauma PI Committee as appropriate
Monitoring interrater reliability and TQIP entry accuracy
Become fluent in AIS/ISS in order to serve as a clinical resource for the registrars
Participates in system performance improvement initiaites locally, regionally, and nationally
Participates in preparations for all designation and verification trauma site surveys.