Quality & Improvement Nurses - Baystate Health

Req#: R21403
Category(s): Nursing, Quality & Improvement Nurses
Full Time / Part Time: Full-Time
Shift: First


Coordinates Baystate Quality Management and Performance Improvement for a  level 1 adult trauma program. Assists in coordination of the Trauma Quality Improvement Program (TQIP) in compliance with the American College of Surgeons.  Adheres to system and department compliance policies, and any applicable laws and regulations.

Job Responsibilities: 

  • Functions as Quality Assurance/Performance Improvement (QAPI) Team Facilitator for the level 1 Trauma program.
  • Serves as resource/liason/educator to both clinical and nonclinical staff members regarding performance improvement processes.. Ensures that systems and/or process issues identified during performance improvement activities are referred to appropriate department(s) or teams for resolution.
  • Utilizes PDSA cycle, lean methodologies, and other quality improvement tools as appropriate in performance improvement activities.
  • Collects data from a variety of sources, including the EMR, Trauma registry and other sources to support identified quality of care and patient safety measures.
  • Manages, implements, and evaluates Quality Assurance/Performance Improvement (QAPI) activities including collecting and analyzing data and preparing formal reports for presentation.
  • Manages the coordination of data collection and reporting of performance improvement (PI) data as needed to meet requirements of external regulatory agencies and third party payers.
  • Tracks risk events including infections and patient harm. Uses data to create QAPI iniatives for prevent further occurrences.
  • Works collaboratively with the Trauma registrars to track and trend occurrences. Facilitates the weekly Morbidity and Mortality conference with the Trauma Medical Director.

Required Experience: 

  • Bachelors in Nursing, MA Nursing License  and CPR required
  • 3-5 acute care in OR, Surgical, Surgical Inter-care or Emergency required
  • PI, Quality Improvement strongly preferred
  • Strong clinical background.  Strong communication, clinical knowledge,
  • Ability to organize and prioritize workload to meet deadlines, ability to facilitate performance improvement process,
  • Ability to lead teams through difficult discussions- for example challenge peer review committee determination based on investigation findings.  
  • Proficient with use of computers including Word and database software


Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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