pso pses pswp - patient safety · jd, mba, cphrm project manager center for patient safety. ......

PSO? PSES? PSWP? You Have Questions, We Have Answers

September 12, 2013

1 Copyright © 2013 Center for Patient Safety. All rights reserved. All or any part of this presentation may not be

reproduced without consent of the Center for Patient Safety.

This presentation is co-hosted by:

Eunice Halverson MA

PATIENT SAFETY SPECIALIST CENTER FOR PATIENT SAFETY

Today’s Presenters

2

Becky Miller MHA, CPHQ, FACHE, CPPS

EXECUTIVE DIRECTOR CENTER FOR PATIENT SAFETY

Kathy Wire JD, MBA, CPHRM

PROJECT MANAGER CENTER FOR PATIENT SAFETY

Objectives for Today’s Session

Following this Webinar, participants will be able to:

Describe the basics of the Patient Safety and Quality Act of 2005 (PSQIA)

Understand the role of Patient Safety Organizations (PSOs) from a national perspective, including implications of the Affordable Care Act

Understand steps to develop a Patient Safety Evaluation System (PSES)

Learn the definition of Patient Safety Work Product (PSWP)

Be familiar with PSO services to assist in safety improvement and reducing harm to patients



The Center for Patient Safety (CPS) Journey

One of the first 10 PSOs to certify with AHRQ – in 2008

Serves as a facilitator, convener, educator and central voice on patient safety issues

Integrates safety culture and other key aspects of safety improvement

– Just Culture, CUSP, TeamSTEPPS™ training

– Survey on Patient Safety (SOPS) (hospital, medical office, pharmacy, LTC)

First in nation to develop services for EMS (culture and PSO services)

Integrating Long Term Care PSO services

Partnered with VergeSolutions in 2013

Copyright © 2013 Center for Patient Safety. All rights reserved. All or any part of this presentation may not be


Federal law and regulation

Intent of the PSQIA

− A safe environment supporting reporting, sharing, and learning about medical errors

− A voluntary approach to proactive prevention of medical errors & patient harm

− Reduction of healthcare costs from error and patient harm

Establishes Common Data Formats for PSOs to collect consistent information from healthcare providers (errors, near misses and unsafe conditions)

Resource: www.pso.ahrq.gov/psos/overview.htm

The Patient Safety & Quality Improvement Act of 2005 (PSQIA)

Copyright © 2013 Center for Patient Safety. All rights reserved. All or any part of this presentation may not be reproduced without consent of the Center for Patient Safety.

Patient Safety Organizations (PSOs)

A PSO is a private or public entity federally listed as a PSO by the Secretary of the US Department of Health and Human Services (HHS)

Meets criteria for certification

– Ability to securely and confidentially collect, analyze and report adverse events

– Required policies and procedures in place

– Staff meets qualifications

– Performs patient safety activities

More information: http://www.pso.ahrq.gov/index.html


http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=PBG8ytiLo1H6AM&tbnid=bBwxUaveQuy1fM:&ved=0CAUQjRw&url=http://axialexchange.com/blog/article/an-overview-of-the-ahrq-patient-engagement-guide&ei=lXcvUvHXJKeZ2QWSlYCADg&bvm=bv.51773540,d.b2I&psig=AFQjCNETNgHn7jkbGqXkriEV7HO3Ha6Ryg&ust=1378928909168853

How Can the PSQIA and PSOs Improve

Safety?

PSOs can aggregate data from many providers to identify risk patterns of care and system failure

Healthcare providers can be comfortable confidentially reporting medical errors, near misses and unsafe conditions with federal protection from disclosure

Providers can work together in a confidential, protected space to share and learn how to prevent mistakes, and,

Participating providers are assured that their safety work will not be used against them.



A National Perspective of PSOs

Currently 78 PSOs in 29 states

Providers (N=4,371)

– 1,897 specialized treatment facilities

– 1,512 hospitals, 311 specialty

– 438 practitioner groups

– 34 Long-Term Care

– 199 other

Source: http://www.pso.ahrq.gov/listing/geolist.htm- 9/2013

AHRQ Annual PSO Meeting, 4/2013

http://www.pso.ahrq.gov/listing/geolist.htm- 9/2013





National Interest

“patient safety events should be reported through the protected environment of federally designated patient safety organization s (PSOs)”

Potential language in future meaningful use regulations

9

National Interest

Institute of Medicine, Health IT and Patient Safety, Building Safer Systems for Better Care, 2012

The CMS Partnership for Patients – Focus on Reducing Harm

The Joint Commission, “Improving Patient and Worker Safety” 2012

National Association for Healthcare Quality (NAHQ) Call to Action, October 2012

Office of the Inspector General (OIG) – Recommendations to CMS

Centers for Medicare & Medicaid Services (CMS), Quality Assurance and Performance Improvement (QAPI) Conditions of Participation (COPs)

10

Two Provisions Related to PSOs and Hospitals:

PSO’s to assist high-need hospitals in reducing readmissions (Section 3025)

Beginning January 2015, “A Qualified Health Plan may contract with: (A)A hospital >50 beds only if the hospital utilizes a Patient

Safety Evaluation System; and the hospital implements a mechanism to ensure that each patient receives a comprehensive program for hospital discharges (meeting certain criteria) OR

(B)A health care provider only if the provider implements quality mechanisms required by HHS” (Section 1311(h))

Patient Protection and Affordable Care Act (PPACA)

Implications of PPACA, SEC. 1311

Qualified Health Plans operating through the new Health Insurance Exchanges (HIEs) can only contract with hospitals > 50 beds that have a patient safety evaluation system (PSES)

A hospital that utilizes a PSES works with a PSO

Enormous incentive for hospitals to work with a PSO no later than January 1, 2015

PSOs are prepared to work with additional hospitals to help them comply with this provision

PSQIA Key Provisions – Processes

Patient Safety Activities

Patient Safety Evaluation System (PSES)

Patient Safety Work Product (PSWP)

Protection of

quality and

safety

discussions and

documents

Protection for

processes


A PSES is

An “over-arching umbrella” of all your patient safety and quality improvement work

Privileged and confidential under the federal PSQIA of 2005




A PSES is The means, mechanisms or systems your organization uses to collect, manage, analyze and communicate information for quality and safety improvement and for reporting to the PSO





Your PSES may contain

information about events, errors, near-misses, quality improvement data, and other patient safety and quality data and information that is developed, investigated, examined, and analyzed by and for your PSES workgroup



Key Provisions – Processes

Patient Safety Activities



Protection of

quality and

safety

discussions and

documents

Protection for

processes


Data, reports, records, memoranda, analyses, or written or oral statements which

are assembled or developed by a provider for reporting to a PSO and are reported to a PSO, or

are developed by a PSO for the conduct of patient safety activities, or

which identify or constitute the deliberations or analysis of, or identify the fact of reporting pursuant to, a PSES

Copyright © 2013 Center for Patient Safety. All rights reserved. All or any part of this presentation may not be



PSWP

What is NOT PSWP?

Patient’s medical record

Billing and discharge information

Any other original patient or provider record

Information collected, maintained or developed separately, or that exists separately from a PSES



Step 1:

Identify and assess current event reporting systems and information flow for patient safety and quality improvement activities, considering:

Your incident reporting system, including how patient safety events are identified, reported and managed through risk management/ patient safety/quality improvement/customer services/peer review and credentialing processes

How this data is shared, processed, documented and maintained (a flowchart of your processes is helpful)

Your committee structure where patient safety and quality data and information are discussed/shared



Establishing Your PSES

Step 2:

Based on your assessment, determine which of these activities and events will and will not be included in your PSES.

(Each organization makes this

decision based upon their unique needs.)





Step 3:

Identify and define the scope and function of your PSES in your PSO policy.

(Your PSO should have a template or

other resources to assist you.)



Key Concepts

Everything you define as being under the umbrella (PSES) is legally protected and confidential at the time the documents are created.

You do not need to report/submit EVERYTHING inside your PSES to the PSO, but you need to submit SOMETHING to show you are actively involved in a PSO.



Getting Started

Ask…

Can my organization benefit from

− Learning from others about causes of medical mistakes and near misses and how to prevent them?

− Obtaining federal legal and confidentiality protections to supplement peer review and attorney-client privileges for quality and safety improvement work?

What type of PSO would best meet my organization’s needs?



Getting Started

Contract with a PSO that meets your needs and can best help

– Assess quality and patient safety information workflows

– Develop PSES and PSWP policies

– Implement confidentiality processes

– Submit, report & analyze patient safety events



The “PSO Social Contract”

PSO’s pledge to…

– provide a safe environment in which to report and discuss adverse events, and

– share the learning obtained from the reporting

Healthcare providers pledge to…

– report complete and accurate information about adverse events, near misses and unsafe conditions to the PSO to feed the learning

Together, healthcare providers and PSO’s pledge to focus efforts collectively on improving the safety of care and preventing harm for all patients


Why Participate in a PSO?

Participate in sharing and learning aimed at preventing medical error and patient harm

Collaborate with others to identify prevention strategies

Gain the support and expertise of PSOs to enhance quality and safety processes and practices

Gain federal protections that fill the gaps left from peer review and attorney client privilege protections

Meet the PPACA requirement

PSO participation as a hedge against onerous state mandated reporting legislation



To Learn More

AHRQ PSO Page http://www.pso.ahrq.gov/

Center for Patient Safety PSO Resources & Information - http://www.centerforpatientsafety.org/patient-

safety-organization-pso/



http://www.pso.ahrq.gov/



http://www.centerforpatientsafety.org/

http://www.centerforpatientsafety.org/patient-safety-organization-pso/









Services & Resources Available

Contact Your PSO for Assistance

Contact the Center for Patient Safety (CPS)

PSO Services (Hospital, EMS, LTC, Culture Surveys)

PSO Consultative Services & Resources

PSO Participation Toolkit

Policy Templates (PSES, PSWP, Confidentiality)

Presentation Templates to educate leaders, workforce and committee

and More

Consultative and Education Service Options



More details on establishing a PSES

Delving into PSWP

Defining a PSES Workgroup and Workforce

The Legal Landscape of PSO Protections

30

Join us Again! Wednesday, October 16 at 1 PM CST


PSO? PSES? PSWP? You Have Questions, We Have Answers

QUESTIONS ? ? ?

Center for Patient Safety www.centerforpatientsafety.org


888.935.8272

Contact our PSO Team Project Manager/Analyst: Alex Christgen – [email protected]

Assistant Director: Carol Hafley, MHA, BSN, RN, FACHE – [email protected]

Patient Safety Specialist: Eunice Halverson, MA – [email protected]

Executive Director: Becky Miller, MHA, CPHQ, FACHE, CPPS – [email protected]

Project Manager: Kathryn Wire, JD, MBA, CPHRM – [email protected]


http://www.centerforpatientsafety.org/








mailto:[email protected]





pso pses pswp - patient safety · jd, mba, cphrm project manager center for patient safety. ......

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