Senior Quality Improvement Specialist - Trauma Services

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

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.