1. Patient Safety Evaluation System (PSES) for Reporting to a Patient Safety Organization (PSO) Jane Bleske, Patient Safety Officer

2. The Why
The Patient Safety and Quality Improvement Act (PSQIA) was enacted by Congress in 2005 to improve patient safety, the final rule took effect in 2009.
The PSQIA was intended to promote shared learning to enhance quality and safety nationally. The Act authorized the creation of Patient Safety Organizations to improve quality and safety through the collection and analysis of aggregated, confidential data on patient safety events.
The process enables PSOs to more quickly identify patterns of failures and develop strategies to eliminate patient safety risks and hazards.
As of January 1, 2017 qualified health plans in insurance exchanges can not contract with a hospital of 50 beds or more unless that hospital has a patient safety evaluation system and reports data to a Patient Safety Organization (PSO).

3. The How
The Vizient (formally UHC) PSO is UNMH’s designated Patient Safety Organization.
Vizient also provides our platform for the PSN (event reporting) System.
A Patient Safety Evaluation System (PSES) is the internal mechanism that a hospital sets up to manage the collection of information that will be reported to the PSO.
This information is known as Patient Safety Work Product (PSWP) and includes data, reports, analyses, etc which could improve patient safety, health care quality, or health care outcomes.
The Information that is collected to improve patient safety and quality of care (i.e., reports, dashboards, minutes, etc) is given legal protection under the PSQIA even if it is not reported to the PSO.

4. PSWP PSWP IS: PSWP IS NOT:
Any data, reports, records, memoranda, analysis, or written or oral statements (or copies) which could improve patient safety, health care quality, or health care outcomes
Which identify or constitute the deliberations or analysis of, or identify the fact of reporting pursuant to, a PSES
PSWP IS NOT:
Patient’s Medical Record
Billing & Discharge Info
Original information required to meet any federal/state/local public health or health oversight requirement (i.e., mandatory reporting requirements)
Any portion of it will be used for disciplinary process or it has been identified as a potential claim

5. The Ask
Teams/Committee’s performing quality/patient safety work will identify Patient Safety Work Product (PSWP)
Minutes
Aggregate Data
Data Analysis
Label PSWP as such, using the provided confidentiality language
Identify the date that the material was created

6. PSWP is protected
Sharing information for the purpose of improving quality and patient safety does NOT jeopardize the confidentiality protection. Of course, and as always, treat Patient Safety Work Product carefully, do not needlessly print, or leave in unsecured areas.
Documentation that the information was collected for reporting to a PSO by use of the following footer and documentation of the date of collection
This material is produced in connection with, and for the purpose of the Patient Safety Evaluation System and/or Review Organization established at the University of New Mexico Hospital, and is therefore confidential Patient Safety Work Product (“PSWP”) and/or confidential peer review material of the University of New Mexico Hospital as defined in 42 C.F.R. § 3.20 and/or the Review Organizations Immunity Act, Section et seq., NMSA 1978 as amended (ROIA).  As such, it is confidential and is protected under federal law 42 C.F.R. §3.206 and/or ROIA.  Unauthorized disclosure of this document, enclosures thereto, and information therefrom is strictly prohibited.

7. Next Steps
IDENTIFY: Qualifying PSWP generated by your Committee/Team: Deliberations or analyses become PSWP the moment they occur (therefore, consider Meeting Minutes, etc).
LABEL: PSWP as such
NOTIFY: The Patient Safety Officer of your qualifying PSWP and who from your committee/team maintains the information. This information will be entered on a master inventory list which is a component of our internal Patient Safety Evaluation System.