PSO PSES PSWP - Patient Safety · JD, MBA, CPHRM PROJECT MANAGER CENTER FOR PATIENT SAFETY. ......
Transcript of 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
3 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.
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
reproduced without consent of the Center for Patient Safety.
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)
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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
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.
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.
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reproduced without consent of the Center for Patient Safety.
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
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
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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)
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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
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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
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reproduced without consent of the Center for Patient Safety.
Patient Safety Evaluation System (PSES)
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
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reproduced without consent of the Center for Patient Safety.
Patient Safety Evaluation System (PSES)
Patient Safety Evaluation System (PSES)
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
16 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.
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
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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
reproduced without consent of the Center for Patient Safety.
Patient Safety Work Product (PSWP)
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
Patient Safety Work Product (PSWP)
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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
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reproduced without consent of the Center for Patient Safety.
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.)
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reproduced without consent of the Center for Patient Safety.
Establishing Your PSES
Establishing Your PSES
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.)
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reproduced without consent of the Center for Patient Safety.
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.
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reproduced without consent of the Center for Patient Safety.
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?
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reproduced without consent of the Center for Patient Safety.
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
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reproduced without consent of the Center for Patient Safety.
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
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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
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reproduced without consent of the Center for Patient Safety.
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/
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reproduced without consent of the Center for Patient Safety.
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
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reproduced without consent of the Center for Patient Safety.
More details on establishing a PSES
Delving into PSWP
Defining a PSES Workgroup and Workforce
The Legal Landscape of PSO Protections
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Join us Again! Wednesday, October 16 at 1 PM CST
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PSO? PSES? PSWP? You Have Questions, We Have Answers
QUESTIONS ? ? ?
Center for Patient Safety www.centerforpatientsafety.org
http://www.centerforpatientsafety.org/patient-safety-organization-pso/
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]
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.