Sentara Health is seeking to hire a qualified individual to join our team as a Trauma Quality Improvement Coordinator.

Position Status: Full-time (40 hours a week), dayshift

Position Location: On-site at Sentara Norfolk General. 1 day from home after training.

Standard Working Hours: 8:00AM - 5:00PM during training. Flexibility with working hours after successful completion of training.

Overview

The Trauma Performance Improvement (PI) Coordinator is responsible for supporting the trauma program’s performance improvement and patient safety processes in accordance with American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) standards, state trauma regulations, and organizational quality initiatives.

This role facilitates case review, data validation, quality monitoring, and multidisciplinary collaboration to ensure continuous improvement in trauma care delivery and outcomes. The PI Coordinator works closely with trauma surgeons, advanced practice providers, nursing leadership, registrars, and quality teams to identify opportunities for improvement and implement corrective actions.

The coordinator supports the trauma program’s performance improvement and patient safety (PIPS) process, ensuring timely case identification, loop closure, documentation, and compliance with trauma center verification standards.

Essential Duties & Responsibilities:

• Coordinates and supports the trauma program Performance Improvement and Patient Safety (PIPS) program.
• Identifies cases for review using audit filters, registry data, complications, and mortality reviews.
• Facilitates timely case reviews with trauma leadership and multidisciplinary teams.
• Tracks and documents quality issues, opportunities for improvement (OFIs), and corrective actions.
• Ensures loop closure for identified performance improvement events.
• Maintains documentation required for ACS trauma center verification and site visits.
• Reviews trauma registry data and quality reports to identify trends and performance gaps.
• Monitors compliance with trauma clinical guidelines, protocols, and pathways.
• Collaborates with trauma registrars to ensure accurate case abstraction and data validation.
• Assists with preparation and submission of TQIP and state trauma registry data.
• Develops reports and dashboards highlighting key trauma quality metrics.
• Prepares cases for Trauma Performance Improvement Committee meetings.
• Coordinates multidisciplinary case reviews, including participation from trauma surgery, emergency medicine, nursing, radiology, and other specialties.
• Documents committee discussions, recommendations, and action plans.
• Supports implementation of system improvements and education initiatives based on case review findings.
• Ensures trauma PI processes comply with:
  • American College of Surgeons (ACS) Trauma Center Standards
  • State trauma system requirements
  • Hospital quality and patient safety policies
• Assists with preparation for State & ACS trauma center verification and re-verification visits.
• Maintains documentation of PI activities, meeting minutes, and loop closure evidence.
• Provides education to trauma staff regarding quality improvement findings and best practices.
• Provides education and guidance to trauma registrars.
• Supports development of trauma clinical practice guidelines and protocols.
• Promotes a culture of safety, transparency, and continuous improvement across the trauma program.

Education

• Bachelor's of Science in Nursing required

Certification/Licensure

• RN Licensure - VA/Compact required

Experience

• Minimum 3 years of clinical ED or ICU, preferably trauma-related, experience.

• Experience with quality improvement, patient safety, or trauma registry preferred

• Knowledge of ACS trauma verification standards and PIPS processes

• Knowledge of Excel and EPIC