Job Summary The Quality Program Coordinator provides leadership for the hospital's trauma program while supporting organization-wide quality improvement, patient safety, regulatory compliance, and performance improvement initiatives. This position collaborates with physicians, nursing leaders, ancillary departments, and hospital leadership to improve clinical outcomes, ensure regulatory readiness, maintain trauma verification standards, and promote a culture of continuous improvement through data-driven decision making and education. Responsibilities Lead the day-to-day operations of the Trauma Program, ensuring compliance with state, federal, and trauma verification standards. Coordinate trauma performance improvement activities, case reviews, data validation, and registry oversight to improve patient outcomes. Analyze clinical and operational data, identify trends, develop reports, and implement evidence-based improvement initiatives. Collaborate with the Trauma Medical Director, Director of Emergency Services, Director of Quality, physicians, nursing leadership, and multidisciplinary teams to improve quality, safety, and regulatory compliance. Develop, implement, monitor , and evaluate performance improvement plans, clinical protocols, policies, and best practices. Develop, coordinate, and oversee the organization's DNV Internal Audit Program, including the annual audit schedule, auditor education and competency, audit execution, documentation, corrective action follow-up, and reporting of findings to leadership to ensure ongoing accreditation readiness. Support hospital-wide regulatory readiness, accreditation surveys, and compliance with

DNV, CMS, OSHA, WV

OEMS, and other applicable standards. Coordinate trauma education, staff development, competency validation, community outreach, and injury prevention programs. Provide education to clinical staff, providers, leadership, and community partners on trauma care, quality improvement, regulatory requirements, accreditation standards, and evidence-based practice. Represent the organization on internal committees and regional or state trauma, quality, EMS, patient safety, and accreditation organizations. Assist with quality reporting, data abstraction, benchmarking, dashboard development, and submission of required regulatory data. Other duties as assigned. Knowledge, Skills & Abilities Minimum three (3) years of clinical nursing experience with trauma, emergency, critical care, quality improvement, or performance improvement experience preferred Knowledge of trauma systems, quality improvement methodologies, DNV accreditation standards, CMS Conditions of Participation, regulatory compliance, healthcare data analysis, and internal auditing principles preferred . Understanding of concepts of TNCC, ACLS, BLS, and PALS .

Light Work:

Frequent lifting and/or carrying of objects weighing up to 10 lbs. with a maximum lifting of 25 lbs. Education Associate's Degree Bachelor's Degree Credentials Registered Nurse (Required) Current West Virginia RN license required. Current West Virginia RN license required.

Work Schedule:

Days Status:

Full Time Regular 1.0

Location:

Stonewall Jackson Memorial Hospital Location of Job:

WV:

Weston:

Stonewall Jackson Memorial Hospital Talent Acquisition Specialist:

Amanda G. Jeffreys amanda.jeffreys@vandaliahealth.org