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Tennessee Hospital Association

PSO Director/Clinical Quality Improvement Specialist

Tennessee Hospital Association


Job Summary

The mission of the Tennessee Center for Patient Safety (TCPS) is to advance Tennessee hospitals’ adoption of proven strategies that enhance the reliability, safety and quality of care received by patients. The TCPS provides extensive education, resources, and direct support to hospitals to accomplish the mission of better outcomes for patients.

The Patient Safety Organization (PSO) serves member hospitals in the collection, aggregation, and analysis of safety events to facilitate shared learning to improve quality and patient safety. The PSO services include a voluntary adverse event/near miss data collection system, comparative analysis and feedback on events, education, and support for participating hospitals within a protected legal environment.


The Clinical Quality Improvement Specialist provides expertise and professionalism to perform the following responsibilities:

  • Support the continuation and ongoing development of the patient safety organization (PSO), both administratively and in creating value for participating member organizations. This position is oriented toward hospital interests with the primary roles being to ensure regulatory compliance; analyze reported data to identify education/strategy needs; plan and implement education/strategies; and lead the marketing and growth of the PSO program. The Clinical QI Specialist supports the collection and analysis of patient safety data and provides feedback to providers to encourage a culture of safety and minimize patient risk and ensure confidentiality and security protections are maintained.
  • Support hospitals in the reduction of hospital acquired conditions (HACs) and readmissions.  Primary roles include implementing quality improvement strategies and interventions, identifying and overcoming barriers to success, and facilitating the capture and dissemination of best practices.

Note:  We currently have a hybrid work environment.

Job Responsibilities


All Areas

  1. The ability to adapt to a changing work environment and meet challenges presented throughout the day.
  2. Must be available for out-of-town travel approximately 20 percent of the time, be able to drive an automobile and maintain a valid driver’s license.
  3. Must be available in the office during regular office hours unless hybrid work arrangement is in place or work assignments require travel to a hospital or other location.

Patient Safety Organization

  1. Maintain knowledge and competencies in adverse event reporting, Quality and Patient Safety Federal Act and Regulations,
  2. Ensure compliance with federal requirements for Agency for Healthcare Research and Quality (AHRQ) designation and maintain readiness for required reviews and audits.
  3. Develop, implement, and monitor the PSO strategic plan with input from PSO members, the PSO Advisory Council, and the Senior Vice President for Tennessee Center for Patient Safety (TCPS).
  4. Support PSO members, as needed, in establishing their patient safety evaluation systems to take full advantage of the federal privilege provided under the law.
  5. Develop and maintain a positive working relationship with senior leadership and key contacts within PSO member organizations.
  6. Identify educational opportunities from data analysis, trends, and member input, and implement education and improvement strategies.
  7. Monitor members’ use of the PSO system and provide technical support to enhance utilization of programs and services.
  8. Work directly with the PSO data collection and analysis vendor to develop and provide feedback to PSO participants regarding analysis of collected data to support member learning and risk reduction.

Clinical Quality Improvement

  1. Participate in the strategic planning for TCPS and identify opportunities to coordinate PSO activities with other TCPS initiatives.
  2. Develop and implement quality improvement strategies and interventions to reduce HACs and improve patient safety practices.
  3. Provide consultation to hospitals through site visits, coaching calls, and provision of tools and resources.
  4. Track and trend data submission of relevant clinical measures at the facility level and support interventions to reach targeted goals.
  5. Utilize evidence-based quality improvement tools and analysis of performance data to prioritize hospital support and implement the strategic plan with individual hospitals in accordance with their particular needs and priorities.
  6. Lead the Sepsis Collaborative, facilitating relevant meetings, guiding implementation of improvement strategies, and evaluating the impact of efforts.
  7. Work as part of the TCPS department to produce content for reports, newsletter, website and presentations; identify and share best practices; present at meetings and events; identify and develop innovative education; and participate fully in department initiatives, ensuring assigned tasks are complete and timely, and assisting others as needed.
  8. Maintain working knowledge of federal and state hospital regulations related to public reporting and value-based quality payment programs.


Volume:  120+ hospitals participating in TCPS; currently, 50+ member organizations in the PSO

Number of people supervised (direct reports):  None


  1. The Tennessee Center for Patient Safety (TCPS) and the THA PSO are under the leadership of the Senior Vice President for TCPS.
  2. The THA Board of Directors and President guide the priorities and initiatives of the TCPS and PSO.
  3. The PSO Advisory Council and the THA Quality Committee may provide input and recommendations to the TCPS and PSO.


Educational AND EXPERIENCE Requirements Needed to Perform the Duties of the Job:

  1. Bachelor’s degree in a clinical or health-related program is required.  Nursing degree is preferred, and advanced degree is desirable.
  2. Minimum of five years of healthcare-related experience, including risk management, quality, or patient safety related experience.
  3. Experience with clinical performance improvement or outcomes measurement.
  4. Experience working with adverse event and healthcare-related data collection activities.
  5. Experience developing and delivering oral presentations.
  6. Experience working with the marketing of health-related programs.
  7. Experience working with individuals and groups from diverse backgrounds.
  8. Experience in relationship building with external entities.
  9. Experience working in multi-disciplinary team-based setting.

Licensing or Other Special Certifications Required:

  1. Current certification or license in professional field, if applicable.
  2. Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Patient Safety (CPPS), or other Continuous Quality Improvement training is desirable.

Skills Required to Perform the Duties of the Job:

  1. Clinical experience and/or quality improvement experience in a hospital setting or related area.
  2. Strong project development and management skills.
  3. The ability to implement quality improvement, patient safety, and clinical interventions.
  4. Excellent written and verbal communication skills, including presenting to small and large groups virtually and in person.
  5. Strong interpersonal and relationship building skills.
  6. The ability to understand, interpret, and apply statistical data and reports.
  7. Strong critical-thinking and decision-making skills.
  8. The ability to develop meaningful reports to track activities of the PSO and hospital quality and safety improvements over time.
  9. The ability to effectively market the PSO program and demonstrate results through increased membership and return on investment.
  10. The ability to research and identify best practices for quality improvement to accomplish requisite goals and objectives.
  11. The ability to work on multiple projects concurrently and effectively handle changes in project requirements.
  12. The ability to learn new subject areas quickly.
  13. Advanced proficiency in the Microsoft suite of computer programs.
  14. Excellent organizational skills.

Additional Information


Health, dental, vision and life insurance

Short- and long-term disability insurance


Paid time off


How to Apply

Please submit your resume and apply through:  https://recruiting.paylocity.com/recruiting/jobs/Details/1432632/Tennessee-Hospital-Association/PSO-DirectorClinical-Quality-Improvement-Specialist.


  • Date Posted: December 9, 2022
  • Type: Full-Time
  • Job Function: Clinician
  • Service Area: Health (Physical, Mental)
  • Salary Range: 90,000-102,000 annually
  • Working Hours: 38.75 hrs/wk; M-F, 8:00am-4:45pm