NC Quality Center Patient Safety Organization
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Contact Nancy Kingsbury for access.
On December 10, 2008 the NC Center for Hospital Quality & Patient Safety (NC Quality Center) became North Carolina's first federal Patient Safety Organization (PSO) as certified by the Agency for Healthcare Research and Quality (AHRQ). "Reducing patient harm and making North Carolina hospitals the safest in the nation is our ultimate goal. That requires shared learning among providers. Until now, there was no system in North Carolina to obtain reliable data to tell us how often medical errors occur," said Dr. Carol Koeble, Director of the NC Quality Center. "To get that information, healthcare providers need somewhere to openly report errors. As a PSO, the NC Quality Center can now collect this data. Then we can analyze the information and start answering questions about the safety of health care."
Mission
To conduct activities that minimize harm to patients by fostering a culture of quality and safety through learning and sharing among healthcare organizations.
Download the PSO brochure
What is a PSO?
A PSO collects, aggregates and analyzes patient safety events that are confidentially reported by hospitals and other healthcare providers. By encouraging voluntary and confidential reporting of serious adverse events a PSO can facilitate a shared-learning approach that supports effective improvements to reduce risk and harm in the delivery of health care.
The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the creation of a nationwide network of PSOs. This was in response to increasing concern about the lack of patient safety event reporting, which in turn prevented the collection of data to make significant patient care improvements. Two major impediments stood in the way of reporting: 1) fear of disclosure and 2) lack of standardized data collection formats to allow for aggregation, trending and analysis of incidents and contributing factors.
What is Patient Safety Work Product (PSWP)?
- Information related to patient safety or quality
- PSWP can take the form of data, reports, records, memoranda, analyses (such as root cause analyses), or written or oral statements for the conduct of patient safety activities
- PSWP is protected when collected for the purpose of reporting to a PSO and is reported to a PSO
What is a Patient Safety Evaluation System (PSES)?
- A PSES defines the processes within an organization for the collection, management, analysis and reporting of PSWP to a PSO.
- For Data to qualify as PSWP, it must be developed within a PSES
- It also includes supporting documents explaining how information enters the PSES, who has access to the system, and the physical space or equipment used by the PSES.
So Why Join a PSO?
Legal Protection
The Patient Safety Act provides two types of protection:
- Confidentiality protections are key to voluntary reporting. The HHS Office of Civil Rights will be monitoring the confidentiality provisions to make sure that information that is assembled and exchanged between providers and the PSO is kept confidential and protected.
- Privilege protections are enforced by the judicial system, which limit or forbid the use of protected information in criminal, civil, administrative or other proceedings
Prevention
By analyzing patient safety event information, a PSO will be able to identify patterns that could suggest underlying or systemic causes of patient risks and hazards to prevent their future occurrence and improve patient safety.
Learning
By facilitating a shared-learning approach, hospitals and providers can learn from each other, make faster improvements and reduce the cost of learning.
It's Good Business!
Insurers, quality groups, payers, employers and the public look favorably on hospitals and providers who participate in PSO activities and desire to improve patient safety and the quality of health care delivery. Participation in any PSO is voluntary and done on a contractual basis.
How Will Data be Used?
Hospitals and providers will submit patient safety event data and corresponding documents such as root cause analysis for evaluation, feedback and aggregation. Reports can be generated at the facility and PSO level. Safety bulletins, best practices and learning opportunities such as webinars and collaboratives will be offered to promote rapid learning of risk reduction strategies. Finally, deidentified data will be sent to the National Patient Safety Database (NPSD) for national trending and learning opportunities.
For additional FAQs see Patient Safety Organizations Fast Facts www.pso.ahrq.gov/psos/fastfacts.htm
Educational Offerings
What are Common Formats?
To promote a common language for submitting patient safety event information, AHRQ developed "Common Formats." The term is used to describe the technical requirements and reporting specifications that allow health care providers to collect, submit and exchange standardized information with a PSO for data reporting, aggregation, analysis, trending and learning. Common Formats will be continually developed, revised and expanded in the future for reporting root cause analysis, effectiveness of improvement actions and for use in other settings such as ambulatory surgery centers, etc.
Common Formats Version 1.0 was released in September 2009. The Common Formats include generic and event specific formats. The generic Common Formats consist of a health care event reporting form (HERF), patient information form (PIF) and summary of initial report (SIR). The event specific Common Formats address the following types of events:
- blood or blood products
- device or medical/surgical supply
- fall
- health care-associated infection
- medication or other substance
- perinatal
- pressure ulcer
- surgery or anesthesia
The generic forms (HERF, PIF and SIR) are completed with each event submission. Depending on the type of event, an event specific form would also be submitted to the PSO.
The Patient Protection and Affordable Care Act (PPACA)
The PPACA has some interesting references to PSOs, advocating the need for hospitals to join a PSO in the following situations:
Hospital Readmission Reduction Program
Beginning in FY2012, the HHS Secretary is responsible for developing a program for hospitals with a high rate of risk-adjusted readmissions to improve their readmission rates through the use of PSOs. (Section 399KK of the Patient Protection and Affordable Care Act)
A readmission includes the admission of the individual to the same or another hospital within a specified time period. In addition, the Secretary is to calculate and make publically available on the Web, information on hospital readmission rates for certain conditions.
Starting in 2013, inpatient prospective payment system hospitals with higher than expected readmission rates will receive decreased Medicare payments for all Medicare discharges. These rates are reported on Hospital Compare. Performance will be based on 30-day readmission measures for heart attack, heart failure and pneumonia. Post-acute providers and critical access hospitals are not included.
Then beginning with FY 2015, HHS can expand this list and add 4 more conditions (COPD and several cardiac and vascular procedures) or any other specified area or medical topic as the Secretary chooses. However, the Secretary should seek measures endorsed or adopted by a consensus organization such as the National Quality Forum.
Health Insurance Exchanges
Beginning on January 1, 2015, a qualified health plan may contract with a hospital greater than 50 beds if the hospital utilizes a patient safety evaluation system and is working with a PSO. State-based health insurance exchanges are to be in place by January 1, 2014, and the compliance date for hospital contracts is January 1, 2015.
Download the full text of the PPACA
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For More Information
Contact Nancy Schanz at 919-677-4105 or ncqc@ncha.org.
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