POSITION SPECIFICS
Title: Quality Improvement Analyst – Trauma Program
(Nurse)
Reports to: Adult Trauma Program Manager
Job Code: 2730
FLSA Status: Exempt
Manager Approval: K. Jung 4-15
Department/Number: Trauma Support, 10140
PD Status: Approved
Bargaining Unit: Non-Rep
HR Approval: CMW 4-15
Pay Grade: 7N
POSITION SUMMARY
Works in collaboration with trauma program leadership to improve the quality of trauma care encompassing the areas and
disciplines of hospital environment that participate in the management of the injured patient. Responsible for the coordination and
facilitation of the Trauma Performance Improvement Program at University of Wisconsin Hospital and Clinics.
Provides oversight and direction for of all performance improvement activities, including data collection, report running for the
trauma registry database, data analysis, trending, submission of data to the scorecard, documentation of performance activities and
benchmarking of data outcomes. Develops and produces graphic presentations of data for the department from a variety of data
sources. The position is responsible for communicating report findings to others throughout the organization, including
recommendations for improvements and focused studies. The incumbent will represent UW Health at a variety of internal and
external meetings. The position is exposed to sensitive information relating to physician peer review, performance improvement
activities, and patient medical record information. Collaborates closely with trauma program leadership to ensure compliance with all
State of Wisconsin statutes and the American College of Surgeons standards related to performance improvement. Participates in
region, state and national performance improvement activities.
MAJOR RESPONSIBILITIES
Leads Performance Improvement Activities

Work in close collaboration with the Trauma Program Manager and Trauma Medical Director.

Take initiative in planning, developing, organizing, and evaluation of the UWHC Trauma Performance Improvement and
Patient Safety (PIPS) Program,

Oversee and supports the written UWHC Trauma PIPS plan. This will include development of quality indicators,
complications and other tracking/trending.

Coordinate performance improvement aspects of the trauma program with appropriate depts., managers, staff and
physicians.

Ensures that UWHC maintains nationally verified American College of Surgeons Level I trauma standards in regards to
performance improvement and other related standards

Participation in the monthly multi-disciplinary Trauma PIPS Committee. Will share appropriate data and document all
information for the peer review protected minutes.

Document all performance improvement activities from daily IMOC rounds, weekly Trauma Review, chart review, peer
review presentation, follow up and loop closure. May include use of quality documentation tools such as the A3 or PCDA.

Maintain secure and confidential documentation of all PIPS activities, including files, minutes, and loop closure.

Work to ensure all PIPS documents interface with the trauma registry

Incorporate prehospital and referring hospitals in the PIPS plan

Support hospital quality and strategic initiatives
Data Acquisition & Analysis, Management for Ongoing Monitoring and Improvement of Patient Care

Work with registry staff to develop and execute queries from the registry, using standard query tools

Identify data collection throughout care continuum

Gather data from internal (existing operational systems, trauma registry, etc) and external (local, state, and national, TQIP)
data sources to establish benchmarks.

Develop and maintains monthly data reporting and tracking

Share trauma related PIPS data with other depts., managers as requested

Oversee data validation efforts to ensure data reliability as it relates to PISP activities.

Oversee the definitions for data abstraction as it related to trauma performance improvement.

Participation in annual review of trauma registry inclusion criteria.
Data Reporting, Presentation and Communication

Design actionable data reports and displays (tabular, graphic and other formats) for various internal and external








audiences that quickly and effectively direct further improvement efforts.
Analyze and display data results with multiple clinical quality improvement strategies.
Collaborate with others in identifying new and improved ways to distribute data and display findings electronically in order
to facilitate access to findings, sharing interpretations, and speed decision-making.
Organize to ensure timely completion of reports.
Add value by directing attention to unintended variation from standards/benchmarks.
Draft clear, concise and cogent data displays as needed.
Teaches and models for department colleagues methods of assuring data quality, for displaying information that enhances
meaning and facilitates decision making for end users/stakeholders.
Based upon extensive clinical knowledge, adds value to report findings by including recommendations for improvements,
focused studies, further trending, etc. Refers select cases appropriately for advanced (e.g. physician) review.
Demonstrate efficiency with Word, Excel, PowerPoint and other related program software.
Outreach & Training and Education Activities




Attends regional (RTAC), state and other meetings as a UWHC trauma representative.
Supports regional, state and national trauma performance improvements activities
Participates in Trauma Quality Improvement Program (TQIP) activities, including attendance at the annual conference
Oversee the outcome letter process to prehospital providers and referring hospitals partners to provide performance
improvement feedback and insight.
Maintain and Enhance Professional Role

Identify own learning needs; update knowledge through attendance at seminars

Develops personal skills that facilitate efficiency, manage workload and set priorities.
Other duties as assigned
All duties and requirements must be performed consistent with the UWHC Organizational
Performance Standards.
POSITION REQUIREMENTS
Education
Minimum
Preferred
1. Bachelor degree from an accredited college or university in nursing
2. Master’s degree in nursing, business or related field.
Work
Experience
Minimum
Preferred
Minimum
Preferred
1. Three (3) years of recent clinical, data analysis or quality improvement experience.
1. Three (3) years of trauma care (Floor, ED, Critical Care, trauma program)
1. Registration as a professional nurse in the State of Wisconsin
Licenses &
Certifications
Required Skills,
Knowledge, and Abilities
1.
2.
3.
4.
5.
6.
7.
8.
9.
Clinical background and knowledge necessary to interpret/analyze patient outcomes.
Superior attention to detail with excellent verbal and written communication skills.
Ability to work independently and be result oriented.
Capable of interacting with all levels of staff.
Strong ability to track data, analyze and interpret numbers, and make recommendations based on
data synthesis in a clear and logical representation to management and peers.
Ability to maintain confidentiality of sensitive information.
Ability to independently handle multiple ongoing or recurrent tasks.
Ability to work well under tight timelines.
Ability to work as part of a team serving multiple customers.
PHYSICAL REQUIREMENTS
Indicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable
accommodations may be made available for individuals with disabilities to perform the essential functions of this position.
Physical Demand Level
x
Sedentary: Ability to lift up to 10 pounds maximum
Occasional
Frequent
Constant
Up to 33% of the time
34%-66% of the time
67%-100% of the time
Up to 10#
Negligible
Negligible
and occasionally lifting and/or carrying such articles as
dockets, ledgers and small tools. Although a sedentary
job is defined as one, which involves sitting, a certain
amount of walking and standing is often necessary in
carrying out job duties. Jobs are sedentary if walking and
standing are required only occasionally and other
sedentary criteria are met.
List any other physical requirements or bona fide
occupational qualifications:

To Apply Contact Melissa below or go to the website
Melissa Holman
UWHealth UW Hospital and Clinics
Senior Nurse Recruiter
800 University Bay Dr, Suite 300
Madison, WI 53705
608-261-0032
608-261-0031 (fax)
mholman2@uwhealth.org
www.uwhealth.org/careers