Share. Learn. Improve.
On December 10, 2008 the NC Center for Hospital Quality & Patient Safety (North Carolina Quality Center) became North Carolina’s first federal Patient Safety Organization (PSO) certified by the Agency for Healthcare Research and Quality (AHRQ) and the 25th in the nation. “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 North Carolina Quality Center. “To get that information, healthcare providers need somewhere to openly report errors. As a PSO, the North Carolina Quality Center collects and analyzes this data, and addresses improvements about the safety of health care.”
To conduct activities that minimize harm to patients by fostering a culture of quality and safety through learning and sharing among healthcare organizations.
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 healthcare improvements.
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.
By providing both privilege and confidentiality, PSOs provide a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data, thus improving quality by identifying and reducing the risks and hazards associated with patient care.
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.
Why Join a PSO?
The Patient Safety Act provides two types of protection:
- Confidentiality protections are key to voluntary reporting. The Health and Human Services Office of Civil Rights monitor 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
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 reduce patient harm.
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, Skilled Nursing Facilities and other providers submit event specific patient safety event data. Corresponding documents can also be submitted 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.
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 are available for hospitals, skilled nursing facilities and are being developed for ambulatory surgery centers and other health care settings.