Midwest Alliance for Patient Safety Patient Safety Organization Getting Started with a PSO. An Illinois Hospital Association Company

Transcription

1 Midwest Alliance for Patient Safety Patient Safety Organization Getting Started with a PSO An Illinois Hospital Association Company

2 Today s Roadmap Objectives: 1. Explain the PSQIA and PSO Basics 2. Learn About PSO Terminology PSES and PSWP 3. Discuss MAPS PSO Member Benefits 2

3 Where the PSO Movement Began Patient Safety & Quality Improvement Act of 2005 (PSQIA) Created a safe environment (the PSO) to support reporting and learning about medical errors Supports a voluntary approach to proactive prevention of medical errors & patient harm Intended to reduce patient harm and costs from error 3

4 Patient Safety Organizations Currently 85 PSOs in 30 states plus Washington DC Majority have specialized focus (i.e., anesthesia, medication safety, vascular surgery, pediatrics) Most have between 10 and 49 members To date, PSOs have collected over 2,000,000 safety reports State coverage of Listed PSO s Note: a PSO may operate in any or all states; each state shows the number of PSOs that serve that state. 4

5 How Do Providers and PSOs Work Together? Providers confidentially report medical errors, near misses and unsafe conditions to PSOs in return for federal protection from disclosure PSOs aggregate event information from member providers to identify risks and system failures Providers across organizations work work together in a confidential, protected space to share with and learn from each other how to prevent mistakes 5

6 PSQIA Confers Legal Protections for Reporting Events to a PSO Privilege: Not subject to subpoena in civil, criminal, administrative proceedings Not subject to discovery Not admissible into evidence Not subject to Freedom of Information Act Confidentiality: Events cannot be disclosed except as permitted under the Act/regulations; improper disclosure can trigger financial penalties 6

7 PSO Patient Safety Activities 1. Improve patient safety and the quality of health care delivery 2. Collect and analyze Patient Safety Work Product (PSWP) 3. Develop and disseminate patient safety information, such as recommendations, protocols, or best practices 4. Utilize PSWP to encourage a culture of safety and provide feedback and assistance to minimize patient risk 5. Maintain procedures to preserve confidentiality of PSWP 6. Provide appropriate security measures with respect to PSWP 7. Utilize qualified staff 8. Operate a Patient Safety Evaluation System (PSES) and provide feedback to participants in a PSES 7

8 New Terminology: Patient Safety Evaluation System (PSES) The regulations say A protected space or system that is separate, distinct, and resides alongside but does not replace other information collection activities mandated by laws, regulations, and accrediting and licensing requirements, as well as voluntary reporting activities that occur for the purpose of maintaining accountability in the health care system. 8

9 Designing Your PSES: First a Policy How do YOU manage adverse events? Events to be reported to the PSO - Adverse events, sentinel events, never events, near misses, HAC, unsafe conditions, RCA, etc Staff roles - who manages, who investigates, who reports Physical and virtual spaces Identify PSWP - event info, RCA, PI plan, committee minutes Adverse event management processes - reporting and investigation policies, procedures and practices; grievance policies and procedures; disclosure of PSWP; pathway for information received from the PSO 9

10 New Terminology: Patient Safety Work Product (PSWP) Includes provider information that: Could improve patient safety, healthcare quality, or healthcare outcomes AND Is assembled by a provider for reporting to a PSO, such as: data, reports, memoranda, written or oral statements, analyses (e.g., root cause analyses, FMEAs) 10

11 Potential PSWP Elements *Consider implications of state law privileges when deciding whether to report peer review information **Report only if facility policy does not consider the videos to be part of the medical record 11

12 PSWP Does Not Include: Patient medical records Billing and discharge information Other original patient or provider information Information that is collected, maintained, or developed separately, or exists separately, from a PSES Information collected to comply with external obligations: State reporting requirements 12

13 Benefits of MAPS PSO Membership Federal privileges and confidentiality protections Peer collaboration and shared lessons Access to ECRI Institute s nationally recognized patient safety research and education Enhancement of organizational safety culture Get ahead of the Illinois Adverse Health Care Event Reporting Law and the Affordable Care Act s January 1, 2017 PSO participation requirement Get involved with your PSO if you aren t already. PSOs are the wave of the future, they are part of the future, clinically, electronically and as part of quality and safety improvements. Dr. William Munier, Director, Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality (AHRQ) Midwest Alliance for Patient Safety PSO

14 MAPS Support Website resources at: Monthly E-Newsletter with Program Updates & News Events Calendar featuring Training & Networking Events MAPS Help Desk Phone & E- mail support 14

15 Publications ECRI Institute Support National PSO Navigators Quarterly publications that focus on key patient safety issues; includes leadership strategies, what adverse events are being reported, and lessons learned. Patient Safety Membership Updates A monthly service offering a summary of patient safety news in the area; Legal and Regulatory, Patient Safety, Hazards and Recalls and well as PSO Updates. Patient Safety E-lerts A special notification of a select topic that includes of Key Contributing Factors, Recommendations and Take Home Points. Proprietary & Confidential; 2014 ECRI Institute PSO 15

16 The MAPS Implementation Process The value of Check-in Calls: 1:1 Guidance for Learning & Planning the logistics for your PSO Feedback on your PSES, PSWP & Document Management Tips for Coordinating your Adverse Event Data Review Progress & Gaps in Program Execution The value of monthly Member Calls: Rotating calls every month for hospitals, physician groups and specialty organizations Opportunity to network and ask questions Share learnings and processes The MAPS PSO team is with you every step of the way from policy development to training to support and analysis of your adverse events. 16

17 MAPS PSO Team Contacts: Helga Brake, PharmD, CPHQ, CPPS Director Midwest Alliance for Patient Safety 630/ Carrie Pinasco, BS, CDM Operations Manager Midwest Alliance for Patient Safety 630/ The Midwest Alliance for Patient Safety (MAPS) was formed for the purpose of engaging in patient safety activities in order to promote a patient centered culture of safety, by improving the quality of healthcare delivery in participating hospitals and other participating healthcare providers. Mission: To promote the adoption of best practices to improve the delivery of safe and quality care to all patients. An Illinois Hospital Association Company 17