Senior Quality Improvement Specialist - Trauma Services

Find your calling at Mercy!

Serves as a Trauma Performance Improvement (PI) Nurse responsible for coordinating the Trauma Performance Improvement and Patient Safety (PIPS) program for trauma and burn patient populations. This role ensures systematic event identification, multidisciplinary review, and documentation of performance improvement activities, including evidence of loop closure, corrective actions, and sustained improvement in alignment with ACS Trauma Center and ABA Burn Center verification standards.

Position Details:

Key Responsibilities:

Trauma Performance Improvement (PIPS) Coordination

• Coordinate the Trauma Performance Improvement and Patient Safety (PIPS) program for trauma and burn patient populations
• Organize and facilitate the multidisciplinary review process, including case identification, preparation, tracking, and follow-up
• Collaborate with Trauma Program leadership, Trauma Medical Director, Burn Medical Director, and multidisciplinary teams to support program goals and regulatory compliance

Event Identification & Audit Filter Management

• Identify trauma and burn performance improvement events from a variety of sources, including registry data, audit filters, incident reports, peer review, and staff/provider referrals
• Ensure effective use, review, and ongoing evaluation of trauma and burn audit filters in alignment with verification standards
• Support development and refinement of audit filters based on trends and program needs

Documentation & Regulatory Compliance

• Maintain accurate, complete, and survey-ready documentation demonstrating:
  • Event identification and screening processes
  • Effective use of audit filters
  • Multidisciplinary review and case progression
  • Loop closure with documented resolution
  • Corrective actions and follow-up
  • Strategies for sustained improvement over time
• Ensure all PI activities meet trauma and burn program regulatory requirements
• Support preparation for site visits, PRQ submission, and internal/external audits

Performance Improvement & Loop Closure

• Facilitate development and implementation of corrective action plans in collaboration with physicians, nursing, and ancillary departments
• Demonstrate loop closure by validating that identified issues have been addressed and resolved
• Monitor outcomes over time to ensure sustained performance improvement and prevent recurrence
• Escalate high-risk or system-level issues as appropriate

Data Management, Analysis & Reporting

• Collaborate with trauma registry staff to ensure data integrity, completeness, and alignment with PI activities
• Track, trend, and analyze PI events and audit filter data to identify opportunities for improvement
• Develop reports, dashboards, and summaries reflecting trauma PI activity, trends, and outcomes
• Apply evidence-based practice standards and benchmark comparisons to support recommendations

Education, Collaboration & Program Support

• Educate and mentor staff and team members on trauma PI processes, including audit filters, case review, and loop closure
• Promote a non-punitive, systems-focused approach to performance improvement
• Support ongoing education and process improvement initiatives related to trauma and burn care
• Collaborate with stakeholders to drive process improvement and sustain outcomes

Additional Job Description:

Minimum Qualifications

• Current Registered Nurse (RN) licensure
• 5 years of related experience (Trauma, Emergency, Critical care, or Burn care)
• Strong analytical, organizational, and communication skills

 

Preferred Qualifications

• Knowledge of Trauma PIPS processes and regulatory standards (ACS, ABA, MO state) strongly preferred
• EPIC and ESO experience preferred
• TNCC Instructor preferred

Why Mercy?

From day one, Mercy offers outstanding benefits - including medical, dental, and vision coverage, paid time off, tuition support, and matched retirement plans for team members working 32+ hours per pay period.

Join a caring, collaborative team where your voice matters. At Mercy, you'll help shape the future of healthcare through innovation, technology, and compassion. As we grow, you'll grow with us.