Trauma Program Manager

The Trauma Program Manager (TPM) co-manages the Trauma Program along with the Trauma Program Director (TMD) and leads South Shore Hospital (SSH) to achieve: 1) optimal outcomes for injured patients and 2) American College of Surgeons (ACS) Trauma Center (Level 2) verification. Working both independently and in collaboration, the TMD and TPM are responsible for the multidisciplinary organization of services, implementation of best practices, trauma performance improvement and implementing processes that lead to achieving both goals. Primary responsibilties of TPM are administrative, performance improvement, clinical, educational, and outreach activities of the Trauma Program as determined by the needs of the program, the TMD, and SSH. The TPM assumes day-to-day, 24/7 responsibility (under the VP of Nursing) for process and performance improvement activities as they relate to nursing and ancillary personnel. The TPM assists the TMD in carrying out the same functions for physicians. The TPM and TMD work together with guidance from the trauma peer review committee to identify events, develop corrective action plans, and ensure methods of monitoring, reevaluation, and benchmarking. (CD 2–17). The TPM collaborates with the TMD, physicians, and other health care professionals to provide clinical and system oversight for the care of trauma patients, ensuring the provision of efficient, quality, cost-effective care. JOB REQUIREMENTS Minimum Education Bachelors required, Masters preferred. Minimum Work Experience 5 years clinical and leadership experience in at least one of the following: trauma, critical care, emergency or operating/recovery room. Trauma Center experience. Special consideration given for experience with Trauma Center verification processes and ACS Trauma Center criteria. Required Licenses / Registrations RN - Registered Nurse or Paramedic (EMTP) or Physician Assistant (PA)1 - Administration    a - Manages the operational, personnel, and financial aspects of the Trauma Program.    b - Serves as a liaison to administration and represent the Trauma Program on various SSH and community committees to enhance and foster optimal trauma care.    c - Supports and adheres to SSH policies, procedures, philosophy, culture, and mission.    d - Interprets and implements SSH policies and procedures, make recommendations for revisions, assist with updating policies and procedures.    e - Participates in the development and planning of goals and objectives related to trauma care.    f - Assist with the development of: a) evidence based clinical practice guidelines; b) Trauma Process of Care (T-POCs); c) policies and procedures based on current literature and research; and d) Input from clinicians and other sources such as information from patient care evaluations.    g - Represents the Trauma Program on various SSH and community committees to enhance and foster optimal trauma care management and  ACS verified Trauma Program.    h - Prepares the Trauma Program budget.  Anticipates trends, changes with the verification process, future needs of the Trauma Program, and growth.    i - Work with all necessary departments to resolve inefficiencies and reduce costs.    j - 1.    Supervise adherence to SSH policies, procedures, and standards through observation, medical record review, staff feedback, and other appropriate sources. 2 - Administration    a - Serves as a liaison to administration, medical staff, EMS, nursing, and clinical departments. 3 - Performance Improvement    a - Monitors clinical processes and outcomes, and system issues related to the quality of care provided:  a) develop quality filters, audits, and case reviews; b) identifies trends and sentinel events; and c) helps outline remedial actions while maintaining confidentiality.    b - Assesss and improves departmental performance.    c - Maintains quality control programs and participates in the SSH’s overall quality control program.    d - Monitors performance of SSH staff involved with the care of trauma patients.    e - Monitors trauma patient outcomes and evaluates for trends.    f - Coordinates with physicians, nurses, other SSH staff, and outside providers to evaluate and address specific patient care issues.    g - Participates in case review.    h - With the TMD: develops, implements and evaluates the quality of care that is multi-disciplinary, patient-outcome focused and patient-family-centered.    i - Coordinates the identification, investigation, reporting, and follow up of incidents and quality issues throughout the program, while maintaining confidentiality.    j - Monitors the trauma team's availability and compliance with policies and standards. 4 - Performance Improvement    a - Coordinates and schedules the morbidity and mortality committee and multidisciplinary review meetings. Co-chair the committees with the TMD.    b - Analyzes trauma registry data to identify trends for strategic planning, performance improvement, outcomes, and compliance with T-POC.    c - Ensures the timely reporting of trauma data submitted to NTDB, TQIP, and MA state trauma registry.    d - Facilitates the measurement of selected outcomes for the trauma patient population. 5 - TQIP    a - Responsible for staff attending required TQIP educational programs: such as On-line tutorials, Monthly web casts, Monthly quizzes, Annual meetings.    b - Assures that data submitted to TQIP is: a) appropriate, timely, and accurate; b) strictly adheres to definitions in NTDB dictionary; c) includes all data required for risk adjustment variables; and d) completed appropriately for all TQIP fields    c - Knowledge of TQIP a. Inclusion and exclusion criteria b. TQIP focused data points c. Understanding of risk adjusted, odds ratio, and confidence intervals d. Understanding of risk stratified    d - Able to interpret reports, identify unexpected outliers, identify affected patients, and drill down for contributing factors.    e - Collaborates with the TMD to present data, discuss contributing factors for outliers, and develop plans to improve outcomes.    f - Collaborates with the TMD and the multidiscipline team to incorporate TQIP best practice into SSH T-POCs.    g - Coordinates TQIP site visits. 6 - Program Initiatives    a - Develops and implements program initiatives.    b - Monitors and maintains compliance with dynamic ACS requirements.    c - Directs preparation for ACS Trauma Center re-verification review.    d - Develops and fostesr collaborative relationships with all SSH departments to facilitate and support quality trauma care.    e - Participates in state and regional trauma care activities    f - Monitors national and statewide trends in trauma care.    g - Serves as a resource for the SSH staff regarding trauma care issues.    h - Plans and implements strategies for ongoing Trauma Program development and improvement.    i - Monitors state and national trends in trauma care.    j - Collaborates with TMD, physicians, and other health care professionals to provide clinical and system oversight for the care of trauma patients, ensuring the provision of efficient, quality, cost-effective care. 7 - Clinical Activities:  Coordinates management across the continuum of trauma care, which includes the planning and implementation of T-POCs, clinical protocols and practice management guidelines, monitoring care of SSH patients, and serving as a resource for clinical practice. 8 - Education    a - Evaluates, directs, and/or provides for intra-facility and regional professional staff development, participate in case review, implement practice guidelines, and directs community trauma education and prevention programs.    b - Participates in the planning, coordinating, and evaluating trauma-related educational programs based on identified needs.    c - Monitors physician and nurse compliance with the educational requirements of the Trauma Program.    d - Ensures staff involved in the care of trauma patients meets educational requirements of the Trauma Program.    e - Participates in the development, coordination and implementation of trauma orientation, nursing education, and in-service programs related to care and management of trauma patients.     f - Seeks and pursues opportunities for internal and external trauma-related educational programs for SSH staff. 9 - Oversee the Trauma Registry - The trauma registry is critical to both Trauma Center verification and trauma performance improvement    a - Develop, design, and monitor the trauma registry to facilitate performance improvement activities, trending, compliance with ACS criteria and research.    b - Monitors/maintains the integrity and accuracy of the trauma registry. a. Develops and maintains processes for data validation. b. Monitors data collection, abstracting, coding, and scoring. c. Ensures the proper maintenance of the trauma registry in collaboration with Trauma Registrars.    c - Assists in data collection related to the trauma patient.    d - Generates reports as needed.    e - Effectively uses data and reports to monitor quality of care, and injury surveillance. 10 - Supervise Trauma Registrars    a - Monitors efficiency, productivity, and accuracy.    b - Monitosr strict use of the NTDB dictionary.    c - Reviews and evaluates data with Trauma Registrars for accuracy, integrity, consistency, and regulatory compliance.    d - Facilitates and monitors Trauma Registrar compliance with educational requirements. 11 - Oversee Trauma Outreach and Injury Prevention Programs.    a - Supervises Injury Prevention Coordinator.    b - Oversees the development and implementation of injury prevention programs.    c - Oversees Trauma Outreach educational and Injury Prevention activities.    d - Provides direction and monitoring of the effectiveness of the program activities. 12 - Consultant and Liaison - Stabilizes the complex network of the many disciplines that work in concert to provide high-quality care. Serve as an internal resource for staff in all departments, and in conjunction with SSH EMS, act as a liaison for internal and external EMS agencies. 13 – Evidence Based Practice - Facilitates design and implementation of evidence based T-POC, CPG, and protocols. 14 - Community and National Involvement in Trauma Care Systems - Participates in the development of trauma care systems at the community, state, provincial, or national levels. 15 - Professional Development    a - Maintains current licensure, certifications, knowledge, and competency of trauma care.    b - Obtains minimum of 16 trauma related CME hours annually.    c - Assesses need and takes initiative in seeking opportunities for personal growth and development.    d - Maintains membership in National and Professional Trauma organizations.    e - Participates in regional and state trauma organizations.    f - Shares information obtained at education programs and conferences with others. 1 - Technology and Learning    a - Participates in continued learning and possesses a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.    b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role. days Responsibilities if Required: Education if Required: License/Registration/Certification Requirements: Registered Nurse - Board of Registration in Nursing (Massachusetts)