Trauma Performance Improvement Nurse - Emergency Department (0.5 FTE)

JOB SUMMARY: The Trauma Performance Improvement Nurse is responsible for leading and coordinating trauma performance improvement, data quality, and compliance activities required to support St. Peter’s Health’s designation under the Montana Trauma Care System. The position ensures continuous evaluation of trauma care processes, facilitates multidisciplinary review of trauma patient outcomes, coordinates trauma registry reporting, and drives process improvement initiatives to enhance patient safety and outcomes.

KNOWLEDGE/EXPERIENCE: Minimum of 3–5 years of clinical nursing experience , ideally in Emergency, Trauma, or Critical Care settings. Previous experience in trauma performance improvement, quality management, or trauma registry preferred.

EDUCATION : Current Registered Nurse (RN) license in the State of Montana (active and in good standing). BSN preferred; MSN or advanced degree in nursing or quality improvement strongly preferred.

LICENSE/CERTIFICATION/REGISTRY : BLS (Basic Life Support), TNCC (Trauma Nurse Core Course) Required. ACLS (Advanced Cardiac Life Support), TCRN (Trauma Certified Registered Nurse) or similar trauma-related credentials highly desired.

APTITUDES: Advanced knowledge of trauma care standards, quality improvement methodologies, and trauma data analysis. Proficiency in trauma registry software, electronic medical records, and quality reporting systems. Excellent communication, project management, presentation, and interpersonal skills.

Key Responsibilities:

Performance Improvement & Quality Assurance

• Lead trauma performance improvement activities in alignment with Montana trauma system expectations and hospital standards.

• Monitor, analyze, and interpret trauma care outcomes to identify trends, deficiencies, and opportunities for improvement.

• Develop, implement, and evaluate action plans addressing system performance gaps and regulatory requirements.

• Facilitate multidisciplinary Trauma PI Committee meetings, case reviews, and peer review processes.

• Support corrective action follow-up and track progress on improvement initiatives.

Data Collection & Reporting

• Support the hospital’s trauma registry, ensuring accurate and timely entry of trauma patient data that meets Montana state trauma register requirements.

• Collaborate with clinical and informatics teams to ensure data integrity and completeness.

• Prepare quarterly and annual trauma quality reports for internal review and state reporting.

• Ensure timely compliance with state trauma registry submission requirements and Montana DPHHS data standards.

Regulatory Compliance & Trauma Designation Support

• Maintain current knowledge of Montana trauma designation standards and administrative rules governing trauma facility performance and registry reporting.

• Assist with preparation for trauma site reviews and re-designation surveys as required by the Montana Department of Public Health and Human Services (DPHHS).

• Coordinate documentation and evidence required to demonstrate compliance with trauma designation criteria.

Education & Outreach

• Provide trauma system education, training, and consultation to clinical staff, Providers, leadership, and new team members.

• Promote continuous learning through participation in trauma quality improvement education and evidence-based practice initiatives.

• Serve as a liaison to pre-hospital partners to support trauma system integration, feedback, and community education.

Collaboration

• Work closely with trauma surgeons, emergency medicine staff, nursing leadership, and interdisciplinary teams to foster a culture of safety and quality.

• Actively participate in statewide and regional trauma care quality improvement discussions and initiatives.