1 EMS PSO Educational Webinars Session 1: Understanding the Patient Safety Evaluation System January 11, 2012 MO MOCPS

2 Agenda An Overview - The Patient Safety and Quality Improvement Act of 2005 Current Reporting Processes PSO 101 & Acronym Soup How will this work in my ambulance service? Next Steps - Homework 2

3 Goals of MOCPS To expand learning from patient safety initiatives through collaboration. To serve as a federally recognized Patient Safety Organization to collect, learn, and share learning about adverse events in an effort to reduce preventable harm. 3

4 Patient Safety & Quality Improvement Act of 2005 (PSQIA) Intent – A safe environment supporting voluntary reporting, sharing, and learning about medical errors – Proactive prevention of medical errors Main provisions – Establishing a national network of PSOs – Providing federal-based legal protections – Definitions for processes and procedures to participate with a PSO and obtain the available protections 4

5 Key Provisions of the PSQIA What is a PSO? – An organization that collects data from participants (you), studies it and develops recommendations for safer care. – The Missouri Center for Patient Safety is a federally- listed PSO. 5

6 MOCPS as a PSO Certified with the US Department of Health and Human Services effective November 5, 2008 Quantros™ contracted as data partner for automated PSO data collection, analysis and reporting Currently have over 180 contracts with hospitals, ambulatory surgery centers (ASCs), and ambulance services Began receiving live data in 2010 from hospitals and ASCs 6

7 Current QI, Personnel, & Legal Processes Within Your Service 7

8 These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety Focused trip reviews - all intubations; all codes/full arrests; all IV insertions Investigation of incident reports Case reviews with the Medical Director (could be scheduled or a special request form he supervisor/manager Quality committee meetings DOCUMENTS YOU ARE COLLECTING Supervisor notes of trip reviews Medical Director case review notes/ recommendations Meeting minutes ACTIONS YOU ARE TAKING NOW QUALITY IMPROVEMENT

9 These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety Documentation of discussions/ s with your attorney Notes from review of trip records Notes from interviews with staff and those involved Notes of discussions with your liability insurer ACTIONS YOU ARE TAKING NOW LEGAL ACTIVITIES DOCUMENTS YOU ARE COLLECTING Getting your attorney involved when bad things happen Reviewing trip records Interviews with staff and those involved Informing liability insurer when necessary All other activities associated with defense of the case

10 These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety Written performance evaluations Documentation of attendance at inservices, skills checks Documentation of remediary training when needed Notes of discussions with the employee and course of action DOCUMENTS YOU ARE COLLECTING ACTIONS YOU ARE TAKING NOW PERSONNEL ACTIVITIES Annual performance reviews Scheduled skills checks Counseling/Coaching Disciplinary action In some cases, discussing termination with your Board

11 These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety Focused trip reviews - all intubations; all codes/full arrests; all IV insertions Investigation of incident reports Case reviews with the Medical Director (could be scheduled or a special request from the supervisor/manager) Quality committee meetings Getting your attorney involved when bad things happen Reviewing trip records Interviews with staff and those involved Informing liability insurer when necessary All other activities associated with defense of the case Counseling/Coaching Disciplinary action In some cases, discussing termination with your Board Annual Performance Reviews Scheduled skills checks

12 Working with a PSO… … you will learn how to more clearly define these 3 activities, and how to maximize the confidentiality protections available to your service. These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety

13 The 101 on Working with a PSO 13 Understanding terminology Applying abstract concepts Redefining your current processes

14 PSO Speak = Acronym Soup Hungry anyone? 14

15 Terminology Basics PSO – Patient Safety Organization - entity that is federally listed as a PSO by the Secretary of the US Department of Health and Human Services (HHS) MOCPS – Missouri Center for Patient Safety MOCPS PSO – Missouri Center for Patient Safety Patient Safety Organization PSQIA – Patient Safety and Quality Improvement Act. Federal legislation signed in to law in 2005 which established the basis for the development of a network of PSOs. Event or Adverse Event – An unintended or unfavorable incident when a patient is impacted as a result of medical treatments, procedures, or other care, regardless of whether or not it caused the patient permanent harm. 15

16 Term you will be hearing FREQUENTLY: PSES – Patient Safety Evaluation System. - The collection, management, or analysis of information for reporting to or by a PSO -It is the mechanism by which information can be collected, maintained, analyzed and communicated -It exists whenever the provider engages in patient safety activities for the purpose of reporting to a PSO What in the world does this mean? 16

17 A slightly easier definition: Patient Safety Evaluation System (PSES): The components and activities that take place within your ambulance service to improve quality, and/or to identify, investigate, respond to and report events and other information to the PSO. *Most important: The work of your PSES has to be done with the intent that the information you gather and create will be reported to the PSO. 17

18 ANOTHER term you will be hearing FREQUENTLY: PSWP – Patient Safety Work Product. Any 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 And what the heck is this? 18

19 Slightly easier…. Patient Safety Work Product is the information that you gather to report to the PSO and the supporting work It can include: data, reports, records (but see next slide), memos, analyses, written or oral statements *Most important: PSWP has to be information that is reported to the PSO or supports the creation of information that is reported to the PSO 19

20 What is NOT PSWP (Patient Safety Work Product) Patient’s medical record (your trip reports) Billing information (anything you send to get paid) Any other original patient or provider record Information collected, maintained or developed separately, or that exists separately from a PSES, for example HR files, purchasing records Material that reflects actual changes made as a result of the patient safety work 20

21 Sounds Complicated. Why Report? Improved patient safety understanding from aggregation of data, benchmarking Protection of your patient safety work from disclosure: – Civil, criminal or administrative subpoenas – Discovery – Freedom of Information Act disclosure – Use as evidence at trial or other proceeding – Use in disciplinary proceedings 21

22 Ok, I get that, but… …how is this going to work in my ambulance service??? 22

23 Tying the basics back to EMS… Think of your current processes as we apply these abstract ideas to something concrete. 23

24 These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety Focused trip reviews - all intubations; all codes/full arrests; all IV insertions Investigation of incident reports Case reviews with the Medical Director (could be scheduled or a special request form he supervisor/manager Quality committee meetings DOCUMENTS YOU ARE COLLECTING Supervisor notes of trip reviews Medical Director case review notes/ recommendations Meeting minutes ACTIONS YOU ARE TAKING NOW QUALITY IMPROVEMENT

25 A Sample Current Investigation Process 25 Crew reports event to Supervisor Supervisor completes investigation: Interviews the crew Reviews trip report Fields calls from the pt/family involved Med Director may review Incident report is filled out Many documents are generated: Interview notes Analysis of trip report, paramedic decision making Notes from phone calls with the pt/family Med Director notes Written staff action only in extreme cases, goes in personnel file. Current Protections: - Attorney-client privilege (if you have involved them, and only applies to limited things) Other documentation goes in your QI files

26 Other current processes Policies for frequency of QI committee meetings Procedures for routine and focused trip reviews Policies for Med Director case review These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety

27 Translation to “PSO Speak…” All of these processes can be established within a Patient Safety Evaluation System (PSES): The “easy” definition: The components and activities that take place within your ambulance service to improve quality, and/or to identify, investigate, respond to and report events and other information to the PSO. Some details of the PSES may differ depending on the process taking place (i.e. event investigation vs. QI meetings) Visual: A Blow Pop….. 27

28 Already-Existing Quality Improvement Activities (hard candy shell)  Examples: incident reporting processes, supervisor investigation, med director review, trip reviews, internal QI data collection  Do not receive the confidentiality protections offered in working with a PSO  Other protections may apply, such as attorney/client privilege Patient Safety Evaluation System (gooey bubble gum):  Any information created in the PSES is considered Patient Safety Work Product (PSWP)  PSWP is eligible for confidentiality protections through working with a PSO. These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety. 28 Patient Safety Evaluation System…. Mmmm, bubble gum!

29 PSES Key Concepts 1.The work and information that takes place and resides inside your PSES is protected from discovery, even before you actually submit it to the PSO. 2.You cannot use that same information residing inside your PSES for any other purposes: a)Cannot use it for disciplinary action b)Cannot use it for legal defense c)Cannot disclose to Bureau of EMS/DHSS BUT…….. These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety

30 PSES Key Concepts 3.Anything you create OUTSIDE of your PSES can still be used for these other needed purposes. This means, notes and documentation you keep for personnel purposes or for legal defense purposes are still accessible and you can continue those processes as before. These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety

31 These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety PSO LEGAL ACTIVITIES PERSONNEL ACTIVITES This is where your PSES will live; all information inside the purple circle is PROTECTED and CANNOT BE DISCLOSED OR USED FOR OTHER PURPOSES. QI Work

32 Homework… 32

33 By January 26 (the next session): Meet with your supervisors, QI personnel, administrator, anyone who is currently involved in this process – and those who will be involved in PSO work – and map out your current process for Incident Report investigation (see Homework Handout #1) Review your current policies on QI committee work; HR disciplinary procedures; and anything associated with reporting incidents to your attorney or liability insurer. Answer the questions on Homework Handout #2. These materials may not be distributed, published, or reproduced, in whole or in part, without prior approval of the Missouri Center for Patient Safety

34 PSO Implementation Steps If you have not returned a signed agreement to us, WE NEED THEM ASAP! EMS Safety Attitudes Questionnaire needs to be administered to all of your staff – Some of you received an on Nov. 15th – many of you did not respond to our request. – Another reminder will be sent out this week – please respond and let us know how you would like to proceed. 34

35 TIMELINE through April, 2012 : 1.Jan./Feb. : EMS Safety Attitudes Questionaire needs to be administered to all of your employees. Educational Webinars on working with the PSO. 2.Feb./Mar.: Develop your service’s PSO policies (templates will be provided on the next webinar) 3.March/April - Have draft policies reviewed by MOCPS 4.By end of April - Begin reporting to MOCPS PSO. 35

36 Questions? Missouri Center for Patient Safety , Carol Hafley, MHA, BSN, RN, FACHE – Missouri Ambulance Association Jason White – 36