Why is it critical for you now?

The national focus on patient safety and quality improvement is gaining momentum. Some describe patient safety and quality care as a national problem of epidemic proportion. Hyperbole? Perhaps. A serious healthcare issue – absolutely.

The national focus on patient safety and quality improvement is gaining momentum.The CMS is focusing on programs that will tie reimbursement to patient safety and quality-related indicators. Private health insurers are also considering doing the same. 

Medical malpractice is an ever-present reality, which, in the absence of evidenced-based care and a culture of safety, will continue to rise and further drive cost through defensive medicine.

While financial incentives can be a motivator, the reality is that improvement in patient safety and quality outcomes leads to better care and fewer adverse events. Patient safety and quality improvement figure prominently in health reform. And today, patient safety and quality care is a differentiator.

What is the value of a Patient Safety Organization (PSO)

The PSO serves as an independent, external expert who can collect, aggregate and analyze patient safety- related information for the purpose of identifying the underlying cause of the events. The information obtained is both privileged and confidential. Knowing the cause (why the event occurred) is critical to taking the right corrective action.

What are PSOs?

Protections offered lead very quickly to an increase in reporting of medical error, which can then be swiftly and appropriately mitigated.Patient Safety Organizations were created through the Patient Safety and Quality Improvement Act of 2005. The Act enables the confidential reporting of adverse events, near misses and dangerous conditions. While voluntary, it provides a vehicle to identify patient safety and quality-related issues. Protections offered lead very quickly to an increase in reporting of medical error, which can then be swiftly and appropriately mitigated. (Note: the data reported is de-identified and cannot be released, even in the de-identified form, without the contributor’s authorization.)

The purpose of the Act is to:

  • Encourage a culture of safety and quality in the United States health care system by providing the legal protection of information reported voluntarily for the purpose of quality improvement and patient safety.
  • Instill greater accountability by raising standards and expectations for continuous quality improvements.

The Act was influenced by the 1999 Institutes of Medicine (IOM) groundbreaking report To Err is Human.

  • In this report the IOM projected that as many as 98,000 patients die each year as a result of medical errors.

A recent (2011) CMS report indicated:

  • 35% of hospital readmissions within 30 days are a direct result of medication errors.

Research on patient safety concludes that professional education, rather than punishment, is the better way to improve patient safety (Just Culture). And while states have adopted peer review statutes, the protection provided by the statutes is often inadequate for the purpose of sharing information to promote patient safety. It’s impossible to improve patient safety and quality without information. To know is a prerequisite to doing.

What are the three key elements provided by the Patient Safety and Quality Improvement Act?

  1. Patient Safety Organizations (PSO): Self-certifying experts listed by the Secretary of Health and Human Services as qualified organizations whose mission and primary purpose are to conduct activities aimed at improving patient safety and the quality of health care delivery.
  2. Patient Safety Evaluation Systems: The collection, management or analysis of information for reporting to or by a Patient Safety Organization.
  3. Patient Safety Work Product (PSWP): Any data, reports, records, memoranda, analysis (such as Root Cause Analysis) or written or oral statements which are assembled or developed by a provider for reporting to a patient safety organization and are reported to a PSO or are developed by a PSO and which could result in improved patient safety, health care quality, or health care outcomes of which identify or constitute the deliberations of analysis of a patient safety evaluation system.

Why are Peer Reviews encouraged?

The Patient Safety Act encourages Peer Review by creating a legal environment for:

  • Privilege:  With limited exceptions, the statute places “Patient Safety Work Product” beyond the reach of Federal and State courts and administrative bodies, even if subpoenaed.
  • Confidentiality: The Act places a burden upon Providers and others not to disclose “Patient Safety Work Product,” absent a permissible disclosure, and imposes penalties for doing so.

How does a PSO work?

A PSO requires the development and adoption by the client of a Patient Safety Evaluation System (PSES) Policies and Procedures

  • Declares PSWP privileged and confidential
  • Calls for segregation of PSWP
  • Sets forth permissible disclosures, some which may be authorized by the client
  • Sets for internal permissible “uses” (internal disclosures) of PSWP, for example internal disclosures of PSWP to Senior Management or Risk Management
  • Prohibits all other disclosures
  • Mandates that all PSWP be marked with the following language “Privileged & Confidential: Patient Safety Work Product Under Federal Law/PSES Date______
  • Identifies method of Transmission
  • Requires maintenance of a PSWP log

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