Surgical Safety CHPSO Claire Manneh, MPH, Director of Programs Rory Jaffe, MD MBA, Executive Director 1
What is a PSO? o Patient Safety & Quality Improvement Act of 2005 (PSQIA) establishes Patient Safety Organizations o Enacts many of the recommendations in To Err is Human Collect standardized information nationwide Develop voluntary reporting Extend peer review protections to data related to safety and quality improvement Develop a culture of safety o Federal Law 2
ACA Mandate: What Does it Say? o Qualified health plans (QHPs) are insurance providers in an exchange o 1/1/20152017, QHPs may contract with a hospital with greater than 50 beds only if: Hospital utilizes a patient safety evaluation system Meaning: collection, management, & analysis of information for reporting to a PSO 3
Implications o QHPs should be including this requirement in their contracts Contracts generally run for one year or more To comply by 1/1/2017, anticipate seeing this requirement before 1/1/2016 o Applies to those hospitals participating in the private insurance market Hospitals of 50 beds of more need to be reporting to a PSO to comply with exchange rules 4
CHPSO o Established by the California Hospital Association o One of the largest PSOs in the country Membership of over 350 hospitals ~60% CA hospitals*; some hospitals in AZ, CO, HI, NM, NV, OR, TX, WA o Membership is complimentary for California Hospital Association members (included in dues) 5
CHPSO Database o Identify emerging issues and the causal factors associated with known patient safety concerns o Share de-identified safety issues to raise awareness and develop improvement strategies o Actively involved in quality and safety initiatives at national and regional levels 6
Benefits of Working with CHPSO o New PSWP privilege and the enhanced communication that goes with it o Collaboration with other providers o Causal analysis critique o Custom research requests o Event feedback and consultation o Educational webinars o Bi-monthly newsletter o Hospital-specific annual report o CHPSO annual report o Legal counsel discussion group o Website knowledge center 7
Patient Safety Work Product Privilege o Patient safety work product is privileged and is not Subject to a Federal, State, local civil, tribal, criminal, or administrative subpoena or order Subject to discovery in connection with a Federal, State, or local civil, tribal, criminal, or administrative proceeding Subject to disclosure pursuant to the Freedom of Information Act or any other similar Federal, State, local, tribal law Admitted in a professional disciplinary proceeding of a professional disciplinary body established or specifically authorized under State law o Patient safety work product disclosed, even if impermissibly, will continue to be privileged and confidential 8
CHPSO Data Collection o This is not new data for you to collect. This is information you are already collecting o Common Formats To promote a common language for submitting patient safety event information, AHRQ developed "Common Formats." 9
These forms are found on AHRQ s PSO website www.pso.ahrq.gov/ Free and publicly available 10
Data Submission o Safety event reports via vendor database o Causal analyses and other documents directly uploaded to secure web portal 11
CHPSO Database o Over 750,000 events Surgery/Anesthesia - 37,732+ Device or Medical/Surgical Supply - 21,879+ 12
Surgical Safety Activities Include: o e-newsletter articles o Alerts Hospital Hardware Hacking http://www.chpso.org/post/hospitalhardware-hacking o Research requests o Safe table fora - surgical safety discussions Operating bed size Anesthetized patients falling off beds 13
RCAs = Causal Analysis o Event feedback and consultation o Mitigation plan 14
Contact HQI Rory Jaffe, MD MBA Executive Director, CHPSO rjaffe@hqinstitute.org Claire Manneh, MPH Director of Programs, HQI cmanneh@@hqinstitute.org 15