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Schedule of Accountabilities of Senior Analyst

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									                         MERCY SAN JUAN MEDICAL CENTER
                                JOB DESCRIPTION


CLASS, TITLE:         Trauma Program Manager        DATE:                 July, 2004

INCUMBENTS:                                         APPROVALS:

DEPT/FACILITY: Trauma Services                      ADMINISTRATION                       DATE
               163-701110

REPORTS TO:           Chief Nurse Executive         HUMAN RESOURCES                      DATE

A. POSITION PURPOSE
   The Trauma Program Manager coordinates and facilitates all components of the Level II
   Trauma Center at Mercy San Juan Medical Center. This includes programmatic,
   multidisciplinary CQI, education, and budget coordination. The Trauma Program Manager
   achieves these responsibilities through collaborative interaction with the Trauma Medical
   Director, Mercy San Juan Hospital staff, managers and administration and non-staff member
   trauma care providers.

B. NATURE AND SCOPE
   1. Reporting Relationships
      a. This position reports to the Chief Nurse Executive.
      b. Reporting to this position are the following:
         1) Trauma Department Senior Program Assistant, who provides administrative
             support for the trauma program.
         2) Trauma QI Coordinator, who collects, analyzes, and facilitates appropriate review
             of data related to quality care of the trauma patient.
         3) Trauma Nurse Practitioner, who provides a case management approach for the
             care for the trauma patient, provides clinical evaluation and support to physicians,
             supports education and QI function of the trauma program.
         4) Trauma Registrar, who collects and inputs data, related to the trauma patients,
             into the “Collector” trauma registry program.
         5) Trauma Injury Prevention Specialist and injury prevention staff who provide
             injury prevention activities to the surrounding community.
         6) Trauma Financial Analyst, who provides in-depth financial analysis and review of
             the trauma patient population. This includes improvement of the trauma
             registration process, billing, management of payor denials, involvement in
             contract negotiations, benchmarking, and other financial components of the
             trauma program.

   2. Position Scope
      This position serves as the interface and coordination between the multiple disciplines
      essential to effectively care for trauma patients through the continuum of care.

       This position has the opportunity to exemplify the Mission and Philosophy of Catholic
       Healthcare West by maintaining a high standard of performance, treating all daily
       contacts with dignity, respect and compassion as a role model in all interactions.

   3. Contacts
Job Description                                                                    Page 2
Trauma Program Manager
      Internal: Includes the managers and supervisors of the Emergency Services,
                Trauma ICU, Trauma Medical/Surgical Unit, Perioperative Services,
                Laboratory, Imagining Services, Rehab Therapies, Trauma Medical
                Director, Nursing and Ancillary Services staff associated with trauma
                patient care.

       Committees: Includes Trauma Peer Review Committee, Trauma Program Performance
                   Committee, County Trauma Audit Committee.

       External:     Includes Sacramento County & Sacramento-Sierra Valley Emergency
                     Medical Services personnel, University of California Davis Medical
                     Center trauma program personnel, Sutter Roseville Medical Center trauma
                     program personnel, State EMS Authority, Trauma Personnel from trauma
                     centers in the United States and abroad, Tri-Analytics/Digital Innovations
                     Trauma Registry, American College of Surgeons Verification Committee,.

       Associations: Include Society of Trauma Nurses, American Trauma Society, Emergency
                     Nurses Association, American Association of Critical Care Nurses or
                     other societies/associations pertinent to trauma care. Trauma Managers
                     Association of California, CHA, California EMS/Trauma Committee

C. MAJOR CHALLENGES
    Clinical: Develop, implement, and review clinical standards relating to trauma care.
     Serve as a clinical resource person for trauma care issues across the continuum of care.
     Oversees functioning of the trauma follow-up clinic.
    Educational: Develop and/or coordinate trauma education programs for all staff based on
     identified needs or standards.
    Quality Improvement: Annually, re-evaluate QI plan for the trauma program and direct
     & assist QI Coordinator in facilitating changes throughout the facility. Assists Medical
     Directors, QI Coordinator, and Trauma Financial Analyst to establish outcome criteria to
     prospectively, concurrently and retrospectively assess compliance with national, regional
     and local standards. Define and maintain interdepartmental relationships to optimize care
     of the trauma patient.
    Trauma Registry: Periodically evaluates appropriateness of trauma registry data points.
     Oversee the collection and input of data for the trauma registry. Generate and evaluate
     routine and special reports from the trauma registry data base.
    Research: Assist in identifying areas of potential research. Assist in the development of
     specific studies with the input of the Trauma Medical Director and other interested
     physicians and staff.
    Administration: Coordinate and participate in leadership for the trauma committee
     structure. Assists all Trauma Medical Directors to coordinate and facilitate medical staff
     education and activities. Prepare for American College of Surgeons verification.
    Marketing/raising visibility of MSJMC as a preferred tertiary referral service.

D. FREEDOM TO ACT
   Independent decision-making:
    Referral of quality issues to the Trauma Peer Review Committee.
    Developing and following own work schedule.
Job Description                                                                         Page 3
Trauma Program Manager
    Scheduling work hours for the Trauma Department Senior Program Assistant, CQI
      Coordinator, Injury Prevention Specialist and Injury Prevention statff, Nurse Practitioner,
      Trauma Registrar and Trauma Financial Analyst.
    Institute measures to comply with state, local and American College of Surgeons
      requirements.
    Participation in internal and external committees and activities.
    Determining capital expenditures and budgetary issues.
    Personnel counseling, hiring and firing.

E. ADDITIONAL KEY ACTIVITIES
1. Clinical – Comply with current standards, attend trauma resuscitations, and         10%
   attend trauma rounds as scheduling permits
2. Education – Coordinate trauma-related education, teach formally and informally,     10%
   based on identified needs
3. Quality Improvement – Annually evaluate PI plan, monitor indicators, follow         15%
   through with planned solutions
4. Trauma Registry – Select, develop data points, maintain accurate data,              8%
   disseminate and evaluate data
5. Research                                                                            2%
6. Administration – Maintain standards for American College of Surgeons                25%
   verification and hospital requirements, monitor trauma program staff
   performance and budget, coordinate committee activities
7. Market/represent MSJMC at local, regional and national forums for Emergency         15%
   Medical Services and trauma issues.
8. Review/Assists with trauma contracting/billing/collections, overall financial       15%
   performance of trauma program and participate in physician recruitment as
   needed.

**Throughout program development and implementation, the priorities will change and
therefore percentages spent in each area will increase or decrease based on the needs.

F. PRINCIPLE ACCOUNTABILITIES
   1. Educational: Coordinate trauma conferences. Participate in the development of trauma
      nursing orientation in all clinical settings. Provide input to department managers for
      trauma nursing competencies for all areas caring for trauma patients. Coordinate
      outreach education program for facilities who refer trauma patients. Participate in
      community and state trauma education and prevention programs.

   2. Quality Improvement: Receive, assess and communicate QI issues to appropriate
      discipline/s promptly. Implement QI recommendations and monitor effectiveness.
      Evaluate clinical standards and systems for effectiveness on an ongoing basis.

   3. Administration: Prepare and provide ongoing evaluation and budget for trauma program.
      Supervise and evaluate activities for trauma program personnel. Represent Mercy San
      Juan Medical Center at local, regional and national forums for Emergency Medical
      Services and trauma issues. Maintain relationship with outlying facilities to facilitate
      optimal patient care, data collection and educational programs.
Job Description                                                                     Page 4
Trauma Program Manager
G. JOB REQUIREMENTS
   1. Special Knowledge
    Familiarity with regulation of trauma systems in California preferred
    Understanding of the Sacramento County trauma plan
    Knowledge of American College of Surgeons criteria for verification of trauma centers.

   2. Special Qualifications
      Required
       Current California RN licensure
       BSN
       4 or more years recent clinical or managerial experience in Critical Care, Emergency
         Department or Trauma Services, 2 years in a Trauma system
       Documented continuing education in trauma care (8 hours in past year)
       Experience in trauma registry development or maintenance
       Experience in educational program planning and presentation
       Experience in planning and implementing quality improvement projects
       Actively involved in professional organizations related to trauma nursing
       TNCC provider

       Preferred
        Trauma program development experience preferred
        Master’s degree
        TNCC instructor
        PALS instructor
        ACLS instructor
        CCRN and or CEN
        Experience in trauma care systems

H. DIMENSIONS

   Annual Operating Budget -
   Payroll
   Total -

   Department Personnel Complement: 4 exempt and 2 non-exempt

I. WORKING CONDITIONS
    Standard hospital environment
    Bends and works in awkward positions
    Protective clothing is worn as necessary
    Patient families are often under emotional distress
    Patients are often acutely ill and in crisis
    Fast-paced environment with shifting priorities
    Safety hazards include exposure to infectious diseases; electrical hazards and toxic
     materials
Job Description                                           Page 5
Trauma Program Manager


J. ORGANIZATIONAL CHART

                                  Chief Nurse Executive
                                 Trauma Program Manager

Peer titles:
         Emergency Services Manager
         Trauma ICU Manager
         Imaging Services Manager
         Laboratory Manager
         Trauma Medical/Surgical Unit Manager
         Perioperative Services Manager

								
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