Description
Job Description
Job Title: Trauma Performance Improvement Coordinator
Department: Surgery
Division: Trauma
Reports To: Pediatric Trauma Program Manager
Approved by: Jasmin Castillo 
Approval date: April 2026
MISSION STATEMENT:
“As New Jersey’s public academic health center, University Hospital is committed to providing exceptional care to every patient, every time.”
SUMMARY (Basic purpose of the job): Responsible for planning, coordinating, and evaluating the performance improvement (PI) program for the Division of Trauma. Responsible for maintenance of compliance with all regulatory agency requirements (American College of Surgeons, Committee on Trauma and the NJ Department of Health and Senior Service). Assists trauma leadership in identifying actual or potential system/process/product issues which must be addressed.
Age/Patient Population(s) Served
Double Click on Box(es) for Your Selection; Select Checked; Click OK for All that Apply
Age of Patient Population Served Population
Bariatric Patients: BMI greater than 40, or greater than 35 with weight related comorbidities
_____ Neonate (birth - 28days) ______ Patient with exceptional communication needs
_____Infant (29 days – less than 1 year) ______ Patient with developmental delays
_____Pediatric (1 - 12 yrs) ______ Patient at the end of life
_____Adolescent (13 – 17 yrs) ______ Patient under isolation precautions
_____Adult (18 – 64 yrs) ______ All Populations
_____Geriatric (65 yrs & older)
_____ Nonage Specific Task (N/A)
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. Service provided is patient centered.
v Actively contributes to creating a friendly, welcoming, and safe environment for UH customers.
v Communicates clearly to ensure understanding.
v Responds to complaints and concerns by resolving issues immediately whenever possible.
v Organizes work process to accommodate customer needs, including internal customers and co-workers.
v Meets or exceeds customer expectations for service.
v Acts as a role model for Service Excellence.
v Maintains professional composure in the workplace.
v Works effectively with team to ensure customer service scores for work area meet/exceed targets.
v Demonstrates respect for patient rights.
2. Establishes and/or contributes to the development of annual goals and objectives of Trauma Division and to the ongoing evaluation of the results obtained.
3. Implements the Performance Improvement Plan of the Division of Trauma.
4. Responsible for the identification of processes, system issues, and concerns as they relate to the multidisciplinary patient care, continuous performance improvement and quality assessment.
5. Guides, directs, and assists interdisciplinary PI teams with the development of PI projects, data collection methodologies, analysis and interpretation of data, and the visual and written presentation of the project.
6. Assists with development of clinical care guidelines.
7. Monitors compliance with and effect of policies, protocols, and guidelines for the Division of Trauma.
8. Assists the trauma leadership in analyzing existing systems, processes, and/or products to identify actual and/or potential system/process/product issues which may affect efficiency, quality, and/or cost effectiveness.
9. Monitors, evaluates, and recommends corrective action for identified variances that affect length of stay, quality of care, cost, and resource utilization.
10. Secures and maintains administrative documents, confidential clinical patient information, physician peer review recommendations and actions taken, and performance improvement documents in a confidential manner.
11. Attends meetings/conferences on a regular basis (to include but not limited to trauma service morning report, Trauma Administrative Group, Trauma PI Group, teaching rounds, Trauma Section and Mortality and Morbidity, and multidisciplinary rounds). Disseminates information as appropriate.
12. Participates in hospital wide PI.
13. In conjunction with Trauma Fellowship Director, coordinates Trauma Grand Rounds and obtains CME for participants.
14. In conjunction with TPM and Nursing Education Department, develops and participates in educational programs and conferences including:
v Basic and advanced trauma nursing
v New and existing policies, procedures, and guidelines
v Student preceptorships.
15. Maintains a high standard of professional responsibility and performance. Maintains clinical competence through routine clinical care experience with the trauma team and/or other avenues. Evaluates own education and professional needs and designs plan to enhance skills.
16. Works in conjunction with Director of Trauma, Trauma physician group, Trauma Program Manager, Trauma APNs, Trauma PAs and Trauma Registry to ensure continuity of care, investigate problems and develop solutions.
17. Understands and adheres to University Hospital’s compliance standards as they appear in University Hospital’s Corporate Compliance Policy, Code of conduct and Conflict of Interest Policy.
18. Keeps abreast of all federal, state and University Hospital regulations, laws, and policies as they presently exist and as they change or are modified.
19. Performs other related duties as assigned.
JOB REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Successful completion of a Bachelor of Science degree in Nursing required, currently licensed to practice nursing in the state of New Jersey required. Masters Degree in a health-related field preferred. Five years of progressive nursing experience, including recent experience in performance improvement and quality assurance. Excellent communication and interpersonal skills. Strong knowledge of computers and computer systems.
Credentials required: Bachelor of Science in Nursing, licensed to practice Nursing in the State of New Jersey
Primary source verification: NJ Division of Consumer Affairs, Board of Nursing, University Hospital's designated Background Check Company
Physical Demands: Position requires standing and walking 1/3 of the time, sitting 2/3 of the time, use of hands, handle or feel 2/3 of the time, reach with hands and arms, 1/3 of the time, stoop, kneel or crouch, talk or hear over 2/3 of the time.
Work Environment: Primarily office, Outpatient, and Inpatient Environment. Moderate noise (examples: business office with computers and printers, light traffic). Moderate exposure to blood, excrements, odors, infection, and communicable disease.
EMPLOYEE ACKNOWLEDGEMENT
I, , Acknowledge Review of This Job Description.
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Employee’s Signature Date:_____________________________________
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Supervisor’s Signature Date:_____________________________________
