The copy your organization submits to CHPSO is always protected. The one exception is if you destroy the original and the original was unprotected, the copy becomes unprotected. However, this exception is rare.
Information you send to CDPH or CMS or accrediting bodies is not protected. Information you collect or develop for the purpose of reporting to those organizations is unprotected. The protected status of some other information is now controversial. CHPSO is trying to work with the American Hospital Association (AHA) for clarity, as the Agency for Healthcare Research and Quality (AHRQ) has provided non-binding, non-regulatory guidance that contradicts the legal positions of AHA, The Joint Commission, CHPSO, and many legal experts.
“Ask CHPSO” is a regular column in the bimonthly Patient Safety News and is intended to provide answers to common inquiries. If you have a question, please contact us at (916) 552-2600 or firstname.lastname@example.org. All inquirers will remain anonymous.