Kathy Wire LeadingAge Missouri September 2,

Fear of using information against provider Inconsistent State protections for safety analyses Inability to aggregate data to improve patterns of care & reduce system failures across providers Copyright © 2015 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. 2

Develop and implement appropriate plans of action to correct identified quality deficiencies. “A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements [of the law].” – Professional liability vs. regulatory or criminal? Few courts have interpreted the privilege, and they have had different results. All indicate it must be narrowly construed. MO (State ex rel. Boone Retirement Center, Inc. v. Hamilton): Only protects documents created by the committee, not information submitted to it Ohio: In civil cases, issue controlled by state law (Bailey v. Manor Care of Mayfield Hts., 2013-Ohio-4927.) Copyright © 2015 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. 3

Applies to skilled nursing homes and assisted living Protects a broad range of information generated by a “committee of health care professionals.” – RN and LPN – Physician – Not RD, CDM, CNA, resident, family, etc. Under recent case, may not apply to information provided to (not generated by) the committee, e.g. expert report Information can be subpoenaed by licensing boards Can be waived Copyright © 2015 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. 4

5 Fancher v. Shields, et al., No. 10-CI-4219, Jefferson Circuit Court (KY 8/16/2011) “[T] sentinel event and root cause analysis information was not prepared for the purpose of facilitating the rendition of legal services…It was not intended to be solely entrusted to the confidence of the…attorney, but was for other business purposes.” “This information was not prepared in anticipation of litigation, but …to comply with the hospital’s (JC) reporting requirements. …..

A safe environment supporting reporting, sharing, and learning about medical errors Proactive prevention of medical errors & patient harm Reduction of healthcare costs from error & patient harm Copyright © 2015 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. 6

To be certified, a PSO must demonstrate: Ability to securely and confidentially collect, analyze and report adverse events Required policies and procedures in place Staff meets qualifications Performs Patient Safety Activities Ability to work with any healthcare provider licensed by a state Provide PSO-related federal confidentiality and legal protections More information: Copyright © 2015 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.

Aggregate data from many providers Providers can confidentially report medical errors, near misses and unsafe conditions with federal legal protection from disclosure Providers to work together in a confidential, protected space to share and learn how to prevent mistakes and improve quality and outcomes of care Providers can be open about safety issues and concerns without fear of their safety work being held against them. Copyright © 2015 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.

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Broader internal discussions – Subject matter: looking back and forward – Pool of participants not limited External sharing PSO’s can support working among multiple providers Center Whitepaper, “PSOs and Transparency: Working Together to Improve Patient Safety”

ACOs and other bundling require providers across care settings to – integrate care – ensure the safety, quality and health of the population – share in cost and cost savings Collaboratively address concerns that affect success for all LTC must be able to work together AND demonstrate its own effectiveness Center Whitepaper, “PSOs Essential to ACO Success”

Work across multiple providers – Identify vulnerabilities that could raise costs or reduce quality – Learn about adverse events and unsafe conditions that exist across participating providers and how they interact – Analyze errors and safety concerns across the ACO – Confidential environment to address improvement Confidential space for the aggregation and sharing of data Flexibility of PSO programs to serve various coordinated care models PSO support tools for investigations, e.g. RCA tool Broad definition of safety, within the context of PSO participation, encompasses quality and patient experience measures, as well as population health work

Pt/ Resident Safety Activities Patient Safety Evaluation System (PSES) Patient Safety Work Product (PSWP) Protection of quality and safety discussions and documents Protection for processes Copyright © 2015 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. 13

“The collection, management, or analysis of information for reporting to or by a PSO” The mechanism by which information can be collected, maintained, analyzed and communicated PSES exists when: – a provider engages in patient safety activities for the purpose of reporting to a PSO – a PSO engages in patient safety activities Copyright © 2015 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. 14

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 © 2015 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. 15

General Information and Resources: Certification/QAPI/NHQAPI.html “…a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes.” Involve members at all levels of the organization, multiple departments, residents and families Identify opportunities for improvement Address gaps in systems or processes Develop and implement an improvement or plan Continuously monitor the effectiveness of interventions Copyright © 2015 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. 16

“Identify your gaps and opportunities” (.p. 16) “Prioritize your opportunities for more intensive improvement work” (p. 16) “Determine what information you need for your PIP” (p. 17) Measure and report on results Observations Research used to develop changes Assessments of your QAPI process in general References are to “QAPI at a Glance” Copyright © 2015 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. 17

Incident reports Logs (falls, weight, wounds, etc. Interdisciplinary teams (fall team, skin team, NAR, etc.) Daily meeting discussion Surveys of staff, residents QAPI oversight team PIP teams Committee, Team minutes Survey on Resident Safety Reports Reports of near miss, concerns Root cause analysis, FMEA QAPI oversight and PIP team D and A Reports on resident incidents Copyright © 2015 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. 18 Data on outcome s and issues for joint pt/ residents

Events reported, near miss or safety concerns Roll-up or comparative data and trends Teams that work on corporate-wide initiatives Surveys of staff, residents QAPI oversight team PIP teams Minutes, reports of committees Survey on Resident Safety Reports Reports of near miss, concerns Root cause analysis, FMEA of shared issues QAPI oversight and PIP team records; D and A Copyright © 2015 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. 19

Events reported, near miss or safety concerns Data on outcomes, trends Teams that work on collaborative-wide initiatives Trend reports developed for oversight of safety and quality Discussion of common issues on SOPS Reports of near miss, concerns Root cause analysis, FMEA of shared issues Collect issues to bring back for QAPI in facility Copyright © 2015 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. 20

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 for all patients Copyright © 2015 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. 21

22 Contract with PSO Develop and abide by policies – Define PSES, PSWP, PSES Workgroup and Workforce Educate appropriate staff Submit data/information to PSO Begin PSO discussion with collaborative providers Copyright © 2015 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.

23 Easiest when all providers are part of common system and it is participant in PSO Also easy when providers are all part of same PSO – CPS has 116 hospital participants in MO – CPS has 140 EMS participants in MO Possible but more challenging when providers participate with different PSO’s Team(s) to work on common issues that affect success of the collaborative endeavor

Copyright © 2015 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. 24 Other Initiatives—PSO can be integrated Surveyors—CMS may resolve issue ?????? – Cannot disclose PSWP – Work with state agency to develop ground rules – They can confirm process; content is confidential Multiple provider: ACO, regional Integrating with other privileges – Attorney-client – State QA/Peer review

Possible info for surveyors or others with an interest: PIP team charters Event reports—basic and factual Logs Actual steps taken to improve: new policies, education for staff, etc. Data to establish the results of QAPI projects, preferably from QI/Oscar reports or logs they will see anyway Copyright © 2015 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. 25

Kathryn Wire, JD, MBA, CPHRM Center for Patient Safety Copyright © 2015 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. 26