PSO Participation for the Leadership Team (Presenter) (Date) 1 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Objectives Learn about the Patient Safety and Quality Improvement Act Understand the benefits of participating with a PSO Learn about the Center for Patient Safety Understand what is a Patient Safety Evaluation System (PSES) and Patient Safety Work Product (PSWP)

Patient Safety and Quality Improvement Act (PSQIA) PSQIA effective July, 2005 with final regulations published November, 2008 Key Provisions of PSQIA: – Allows formation of Patient Safety Organizations (PSOs), which are private or public entities that are federally listed by the Secretary of the US Department of Health and Human Services (HHS). Purpose of PSOs: Undertake efforts to improve patient safety and quality of health care Develop and implement processes for voluntary and confidential reporting of adverse events and for providing feedback to participants Participate in a national network of patient safety databases Work with providers to identify and analyze threats to patient safety and other quality of care problems – Provides confidentiality to entities and individuals who report to a PSO – Provides protection from discovery of work product in legal proceedings (with defined exceptions) 3 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Why We Chose to Participate in a PSO 1.Share the good work we are doing as transparency contributes to improved patient safety for all! 2.Take advantage of federal level confidentiality protection for safety work product: – Protects most quality and patient safety notes, information, data, reports, medical director reviews, peer review – what we define as being inside our Patient Safety Evaluation System – Protect patient safety discussions and analysis currently taking place between hospitals and EMS providers, i.e. trauma, STEMI and stroke regional committees 4 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Why We Chose to Participate in a PSO 3.Benefit from protected group discussions with other PSO participants on specific cases and broader safety and quality issues. 4.Active participation in PSO provides strong counter- argument to current or future proposed bills requiring mandatory reporting to state and federal entities. 5 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Center for Patient Safety PSO The Center for Patient Safety (CPS) was one of the first ten federally listed PSO’s in the nation effective November 5, 2008 First PSO to be working with EMS; they have over 100 EMS agencies working with them and over 100 events in their database To participate in the CPS PSO we have: – Signed a contract – Developed/ing PSO policies (with assistance of CPS staff) to define patient safety evaluation system (PSES) and patient safety work product (PSWP) – Forming and educating our PSES Workgroup – Will be submitting data to the PSO via a secure web portal 6 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

KEY CONCEPTS

Patient Safety Evaluation System (PSES) The mechanism by which patient safety and quality information can be collected, maintained, analyzed and communicated It exists whenever the provider engages in patient safety activities (see next slide) for the purpose of reporting to a PSO For us, this will encompass our [add in your policies, committees, processes, anything else here you are including as part of your PSES] **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Definition of Patient Safety Activities Efforts to improve patient safety and health care quality Collection and analysis of Patient Safety Work Product (PSWP) Development and dissemination of information to improve patient safety Utilization of PSWP to encourage a culture of safety, and provide feedback and assistance to minimize patient risk Maintenance of procedures to preserve confidentiality of PSWP Provide appropriate security for PSWP Use qualified staff Activities related to the operation of a PSES and provision of feedback to participants 9 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Patient Safety Evaluation System (PSES) Workgroup The PSES Workgroup will be the core individuals/committees who will routinely perform patient safety and quality analysis and improvement work, as outlined in [agency/organization to define what policies, processes, etc. this includes] Other individuals with special subject matter expertise may be brought in the Workgroup as needed for work on specific events or issues – such as equipment vendor reps, suppliers, and others. All PSES Workgroup members must sign a confidentiality agreement specific to PSWP. The make-up of this group and its responsibilities are defined in our PSO policy. 10 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Patient Safety Work Product (PSWP) Any data, reports, records, memoranda, analyses, or written or oral statements which could improve patient safety, quality or health care outcomes, and which: – a provider assembles as part of its reporting to a PSO and which it does report, or – reflect the work of the PSES or the fact that information was reported to the PSES PSWP is confidential and should not be disclosed **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Examples of PSWP to submit to PSO Adverse event, near miss and unsafe condition reports, including but not limited to: – Medication errors – Airway management errors – Equipment/device/supply errors – Aircraft issues impacting patient care – Stroke and STEMI response times – Any other safety issue effecting patient care Root Cause Analysis, Clinical Event Investigation Reports, minutes from committee meetings, others 12 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Patient Safety Work Product PSWP does not include: – patient flight records, billing information or any other original patient or provider information – Data and reports generated for submission to external agencies to meet mandatory or voluntary reporting requirements – Improvements, process and policy changes, and Action Plans made as a result of work within the PSES or the PSO PSES Workgroup determines whether information developed in the PSES, or reported to it, will be reported to the PSO. 13 **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Putting It All together [Agency/organization name] has established and defined a Patient Safety Evaluation System (PSES) AND Patient Safety Work Product (PSWP) [Agency/organization name] is establishing a PSES Workgroup, who discusses, analyzes and manages the PSWP to determine: What should be shared with workforce to improve patient safety and quality of care What to submit to the PSO for broader learning Each member of our PSES Workgroup agrees to maintain confidentiality of all PSWP. [Agency/organization name] will submit data and other information to the secure PSO database. **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Questions or Assistance CPS Staff who will gladly assist with PSO establishment and answer questions: Center for Patient Safety **For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety** Becky Miller, MHA, CPHQ, FACHE, CPPS Executive Director Carol Hafley, MHA, BSN, RN, FACHE, CPPS Assistant Director Eunice Halverson, MA Patient Safety Specialist Kathy Wire, JD, MBA, CPHRM Project Manager Alex Christgen Project Manager/Analyst Michael Handler, MD, MMM, FACPE Medical Director Amy Vogelsmeier, PhD, RN, GCNS-BC, Contractor