1

PSO Education for [agency/organization]’

s PSES Workgroup

(Presenter)(Date)

**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Objectives

• Learn about the Patient Safety and Quality Improvement Act

• Understand the benefits of participating with a PSO• Learn about the Center for Patient Safety• Understand what is a Patient Safety Evaluation

System (PSES) and Patient Safety Work Product (PSWP)

• Learn the functions and responsibilities of the PSES Workgroup

Patient Safety and Quality Improvement Act (PSQIA)

• PSQIA effective July, 2005 with final regulations published November, 2008

• Key Provisions of PSQIA:– Allows formation of Patient Safety Organizations (PSOs), which are private

or public entities that are federally listed by the Secretary of the US Department of Health and Human Services (HHS). Purpose of PSOs: • Undertake efforts to improve patient safety and quality of health care • Develop and implement processes for voluntary and confidential reporting of

adverse events and for providing feedback to participants• Participate in a national network of patient safety databases• Work with providers to identify and analyze threats to patient safety and

other quality of care problems– Provides confidentiality to entities and individuals who report to a PSO– Provides protection from discovery of work product in legal proceedings

(with defined exceptions)

3**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Our PSO Participation

• Air Evac is a contracted participant in the Center for Patient Safety PSO

• CPS was one of the first ten federally listed PSO’s in the nation effective November 5, 2008, to provide legal protection and processes for reporting, learning and sharing to improve the safety and quality of care provided

4**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Why Air Evac Chose to Participate in a PSO

1. Share the good work we are doing as transparency contributes to improved patient safety for all!

2. Take advantage of federal level confidentiality protection for safety work product:– Protects most quality and patient safety notes,

information, data, reports, medical director reviews, peer review – what we define as being inside our Patient Safety Evaluation System

– Protect patient safety discussions and analysis currently taking place between hospitals and EMS providers, i.e. trauma, STEMI and stroke regional committees

5**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Why Air Evac Chose to Participate in a PSO

3. Benefit from protected group discussions with other PSO participants on specific cases and broader safety and quality issues.

4. Active participation in PSO provides strong counter-argument to current or future proposed bills requiring mandatory reporting to state and federal entities.

6**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

KEY CONCEPTS

Patient Safety Evaluation System (PSES)

• The mechanism by which patient safety and quality information can be collected, maintained, analyzed and communicated

• It exists whenever the provider engages in patient safety activities (see next slide) for the purpose of reporting to a PSO

• For Air Evac, this will encompass our Clinical Quality Assurance; Clinical Adverse Event Reporting; and ________ policies, in addition to our new Peer Review process [add in anything else here you are including]

**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Definition of Patient Safety Activities

• Efforts to improve patient safety and health care quality• Collection and analysis of Patient Safety Work Product

(PSWP)• Development and dissemination of information to

improve patient safety• Utilization of PSWP to encourage a culture of safety, and

provide feedback and assistance to minimize patient risk• Maintenance of procedures to preserve confidentiality

of PSWP

9**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Patient Safety Evaluation System (PSES) Workgroup

• The PSES Workgroup will be the core individuals/committees who will routinely perform patient safety and quality analysis and improvement work, as outlined in our Clinical QA; Clinical Adverse Event Reporting; and _______ policies.

• Other individuals with special subject matter expertise may be brought in the Workgroup as needed for work on specific events or issues – such as equipment vendor reps, suppliers, and others.

• All PSES Workgroup members must sign a confidentiality agreement specific to PSWP.

• The make-up of this group and its responsibilities are defined in our PSO policy.

10**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Patient Safety Evaluation System (PSES) Workgroup

• Air Evac’s PSES Workgroup will include [fill in the blank here]

• PSES Workgroup determines whether information developed in the PSES, or reported to it, will be reported to the PSO [this is one potential function; you will have Air Evac specific functions you will want to include here].

11**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Patient Safety Work Product (PSWP)

• Any data, reports, records, memoranda, analyses, or written or oral statements which could improve patient safety, quality or health care outcomes, and which:– a provider assembles as part of its reporting to a PSO and

which it does report, or– reflect the work of the PSES or the fact that information

was reported to the PSES

• PSWP is confidential and should not be disclosed

**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Examples of PSWP to submit to PSO

• Adverse event, near miss and unsafe condition reports, including but not limited to:– Medication errors– Airway management errors– Equipment/device/supply errors– Aircraft issues impacting patient care– Stroke and STEMI response times– Any other safety issue effecting patient care

• Root Cause Analysis, Clinical Event Investigation Reports, minutes from committee meetings, others

13**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Patient Safety Work Product

• PSWP does not include:

– patient flight records, billing information or any other original patient or provider information

– Data and reports generated for submission to external agencies for voluntary reporting or to meet mandatory reporting requirements

– Improvements, process and policy changes, and Action Plans made as a result of work within the PSES

14**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Putting It All together

• Air Evac has established and defined a Patient Safety Evaluation System (PSES) AND Patient Safety Work Product (PSWP)

• Air Evac is establishing a PSES Workgroup, who discusses, analyzes and manages the PSWP to determine:• What should be shared with workforce to improve patient safety and

quality of care• What to submit to the PSO for broader learning

• Each member of our PSES Workgroup agrees to maintain confidentiality of all PSWP.

• Air Evac will submit data and other information to the secure PSO database.

**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**

Questions or Assistance

(Enter Organization PSO contact information)

Additional Information:Center for Patient Safety888-935-8272www.centerforpatientsafety.org

16**For internal use by Center for Patient Safety PSO Participants. May not otherwise be photocopied, published or reproduced in whole or in part without the permission of the Center for Patient Safety**