U

UCSF

Public health sciences university in San Francisco

Trauma Performance Improvement Nurse

Full-TimeUpdated on 10/23/2026
$121.9k - $277.1k
Senior
Bachelor's, Master's
Oakland, CA, USA
In Person
Medical, Clinical & Veterinary

About the job

Requirements
  • At least 5 years of experience working as a Registered Nurse in a pediatric acute care hospital; trauma, emergency department, and/or critical care experience is preferred.
  • A bachelor's degree in nursing or another healthcare profession, or comparable clinical education and/or experience, such as a master's degree in a health sciences profession, advanced practice, or clinical nurse specialist experience.
  • In-depth knowledge of quality improvement standards, clinical chart review and abstraction, and regulatory requirements.
  • In-depth knowledge of quality improvement models, tools, and techniques, including data collection, abstraction, validation, analysis, and reporting, and the use of performance and benchmark indicators.
  • Knowledge of Alameda County trauma center designation requirements and American College of Surgeons Trauma Verification standards; this knowledge may be acquired within 3 months of hire.
  • Knowledge of Abbreviated Injury Scoring, Injury Severity Scoring, and trauma registry processes; a trauma registry course may be completed within one year of hire. Experience with Lancet Trauma One Registry is preferred.
  • ICD-10 coding training.
  • Advanced organizational and project management skills, including the ability to lead a team, prioritize tasks, and complete projects on schedule.
  • Advanced interpersonal skills for collaboration with clinical and technical staff and external regulatory agencies, and for mentoring lower-level quality improvement staff.
  • Ability to convey complex clinical, technical, and educational information verbally and in writing, and to produce reports, documentation, and presentations.
  • Ability to generate reports from the trauma registry and other data sources, including the electronic medical record and manually captured data.
  • Proficient understanding of pathophysiology and medical terminology, and the ability to apply this knowledge to abstract and review data for compliance with unit and organizational standards.
  • Current knowledge of national and regional trauma registry requirements and practices, including applicable clinical and database knowledge and skills; this may be learned within 6 months of hire.
  • Ability to seek out current evidence and resources to facilitate improvement in clinical care, including networking with internal and external resources such as TQIP.
  • Knowledge of structures, standards, procedures, protocols, and guidelines needed for the role, and ability to identify gaps and support the development or revision of standards based on current evidence-based practice.
  • Current California Registered Nurse licensure.
  • Current American Heart Association Basic Life Support certification.
  • Completion of the AAAM AIS Coding Course and American Trauma Society Registrar Basic and/or Advanced Course; these may be completed within one year of hire.
  • Current ICD-10 course certificate, obtained within the past 5 years; the course may be completed within one year of hire.
Responsibilities
  • Establish and supervise performance improvement and clinical documentation processes to promote excellence in trauma patient services.
  • Evaluate clinical practice based on patient outcomes, cost-benefit in care provision, and patient access to the healthcare delivery system.
  • Support strategic planning and implement continuous quality improvement programs.
  • Participate in trauma performance improvement evaluation, case review, solution generation, and implementation to improve trauma patient care.
  • Write reports and present data graphically to promote process improvements, improved outcomes, and optimal patient care.
  • Maintain the trauma registry database and assure the quality, accuracy, confidentiality, and timely entry of registry data according to service standards, leadership needs, regulatory requirements, and applicable deadlines.
  • Identify cases warranting review during trauma registry data entry, complete data abstraction, and collect, analyze, and report trauma data for quality improvement tracking, injury research, and prevention.
  • Coordinate trauma registry management, data analysis and reporting, performance improvement, injury prevention, and community outreach initiatives.
  • Participate in or lead clinical and technical teams on broad-scope projects using advanced quality improvement models to develop plans, criteria, and benchmarks.
  • Prepare and implement the department quality improvement plan, including daily monitoring, evaluation, closure, or referral of patient-specific and trending performance improvement issues.
  • Support hospital quality goals and develop and implement department objectives that reflect those goals.
  • Participate in quality improvement monitoring of self and peers and notify appropriate staff of opportunities to improve patient care.
  • Prepare data and coordinate continuous quality improvement activities, including Trauma M&Ms, Trauma Advisory, HELI, MQIC, and Trauma PI Steering activities.
  • Prepare quarterly quality improvement reports and collaborate on strategies to improve patient care.
  • Conduct daily clinical rounds and concurrent entry to monitor clinical processes, outcomes, system issues, and trends using quality filters, reports, audits, and case review; report identified issues and trends to the Trauma Program Manager and Trauma Medical Director.
  • Follow up on problems identified through quality improvement processes, including outreach to pre-hospital and outside-hospital providers to seek or provide information pertinent to performance improvement.
  • Support clinical areas with data management activities and projects involving significant clinical complexity and organizational scope, and develop relevant quality indicators, structures, and measures.
  • Prepare incident reports and conduct quality improvement reviews of complex mortality cases, sentinel events, readmissions, and other cases flagged by screening criteria; identify urgent reviews and collaborate with management on appropriate responses.
  • Attend and co-lead trauma department meetings at 80% compliance and participate in unit and hospital quality improvement activities.
  • Apply trauma-specific clinical practice standards to identify opportunities for improvement and participate in validation of quality improvement monitoring data.
  • Maintain the trauma services quality improvement plan and follow National Trauma Data Bank, American College of Surgeons, and department standards, procedures, protocols, and guidelines.
  • Report data indicating immediate patient risk to the Trauma Program Manager, Trauma Medical Director, or Director of Trauma, and support risk management activities.
  • Engage with Trauma Quality Improvement Program staff to support compliance with standards and use risk-stratified benchmark reporting for the trauma performance improvement and patient safety process.
  • Participate in registry meetings, in-services, continuing education, and Alameda County EMS-A Trauma Audit Committee meetings when assigned.
  • Oversee or perform timely and accurate submission of clinical care quality and patient safety data to internal departments and outside agencies.
  • Evaluate documentation for accuracy and completeness, abstract and enter data concurrently for trauma patients, and validate data accuracy and database completeness.
  • Ensure data is entered concurrently for admitted patients and within one month of discharge for patients sent home from the emergency department.
  • Coordinate database changes with Alameda County EMS-A, the National Trauma Data Bank, the Trauma Quality Improvement Program, and Trauma Services leadership.
  • Retrieve demographic and financial information through the electronic health record, follow applicable inclusion criteria, protect data confidentiality, and comply with HIPAA regulations and standard work instructions.
  • Analyze and interpret complex data, summarize statistical findings, and develop reports, dashboards, presentations, action plans, and executive summaries.
  • Prepare requested reports for presentation, use registry data to target and monitor performance improvement initiatives, generate reports for monthly committee meetings, create basic and advanced reports, suggest queries and reports based on trends, and report trends to Trauma Services management.
  • Identify statistical trends, problems, and potential issues in patient care and services; participate in or lead project teams to investigate issues, implement corrective plans, and monitor effectiveness.
  • Participate in American College of Surgeons verification site reviews and data validation, Trauma Quality Improvement Program, and National Trauma Data Bank meetings when requested.
  • Research best practices and implement improvements in data collection and reporting processes or systems; maintain required professional licensure, certification, or registration.
  • Provide technical advice and counsel on complex quality improvement issues involving functionality, efficiency, performance improvement, and program development.
  • Participate in staff development for unit, division, and hospital personnel concerning trauma patient care; share knowledge and suggestions for improvement with the Trauma Services team.
  • Maintain and share current knowledge of the trauma registry, including AIS, ICD, and E-coding, and monitor acceptable data abstraction and entry performance.
  • Participate in developing and maintaining registry work instructions and reference information for providers concerning performance improvement.
  • Support trauma education as assigned, including serving as a TNCC instructor, and participate in peer review.
Desired Qualifications
  • Post-graduate degree in health sciences.
  • Certified Specialist in Trauma Registry; certification may be completed within one year of hire.
  • Certified Abbreviated Injury Scale Specialist.
  • LEAN training or certification, or similar formal quality methodology training.
  • Current Trauma Nursing Core Course certification.
  • Experience with trauma, emergency department, and/or critical care nursing.
  • Experience with Lancet Trauma One Registry.
  • Advanced critical thinking and problem-solving skills to manage complex information and responsibilities, assess problems, and develop and implement timely solutions.
  • Advanced knowledge of administrative and business software packages and specialized quality data management applications.
  • Advanced skills in influencing and persuading staff, management, and clinicians across departments.

About the company

UC San Francisco is a public research university in San Francisco focused solely on health sciences, combining professional education with biomedical research and patient care. Its schools of dentistry, medicine, nursing and pharmacy train clinicians and scientists, while teams investigate cancer, immunology, genomics and neuroscience. UCSF Medical Center and Benioff Children's Hospitals connect clinical care with faculty research and training, and university clinics serve patients across Northern California. Founded in 1864, UCSF is the University of California campus dedicated to graduate and professional education and biomedical research, based in San Francisco.

Company Size

10,001+

Company Stage

N/A

Total Funding

N/A

Headquarters

N/A

Founded

1864

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