“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 info@chpso.org. All inquirers will remain anonymous.
A patient safety evaluation system (PSES) is the system you use to collect, manage and analyze information (patient safety work product) for reporting to the CHPSO Patient Safety Organization. CHPSO has templates to help you get started. It is important to remember that only those incident reports and other documents, such as Event Analysis or sometimes called RCAs, which are collected with the intention of submitting to CHPSO, will be protected from discovery as patient safety work product.
The reporting requirements leave it up to the hospital as to what they wish to report. We recommend members submit all types of events, from near misses to severe harm. If a member hospital chooses to report solely medication errors, “Medications” is the only event category protected under PSWP. If a surveyor or external legal counsel wishes to view a surgical event from that hospital, it is not protected by PSWP privilege.
Membership to CHPSO Patient Safety Organization is complimentary to members of the California Hospital Association (CHA) and the regional associations: Hospital Council of Northern and Central California, Hospital Association of Southern California, and Hospital Association of San Diego and Imperial Counties). There is a nominal fee for other organizations. A fee schedule is available on the prospective members section.
A number of healthcare organizations ask why they should join CHPSO or another federally listed Patient Safety Organization (PSO). One benefit is to obtain federal protections for certain patient safety data. These protections facilitate broad sharing of patient safety information both within and across organizations, speeding learning and facilitating the elimination of patient safety hazards. As part of this protection, you can collaborate with other hospitals and healthcare organizations, usually at a safe table meeting.
Materials that are submitted to a peer-review disciplinary hearing or to Human Resources for disciplinary actions cannot have Patient Safety Work Product status in the organization, due to the restrictions on the use of Patient Safety Work Product in hearings and legal proceedings. However, these documents may be submitted to CHPSO and the copy in the possession of CHPSO is legally protected.
A previous Ask CHPSO article, Does our hospital have to submit event report data to the PSO by January 1, 2017, highlighted how a hospital can fulfill the requirement of the Affordable Care Act to either report to a PSO or have an evidence based initiative based on the evaluation of safety reports. CMS states that HIINs (Hospital Improvement Innovation Network) satisfy the non-PSO reporting option.
Since many of its members are outside California, CHPSO in 2015 changed its name from the California Hospital Patient Safety Organization to CHPSO. CHPSO members currently include healthcare organizations in nine states: Arizona, California, Colorado, Hawaii, Nevada, New Mexico, Oregon, Texas, and Washington. As one of the first federally-listed PSOs through the Agency for Healthcare Research and Quality (AHRQ), CHPSO welcomes members from all states and US territories.
HIPAA may also apply, in which case the retention period would be the greater of the HIPAA retention policy or the following recommended Patient Safety Work Product (PSWP) retention policy:
Section 1311(h) of the Affordable Care Act requires Qualified Health Plans (QHPs) to contract with certain hospitals that use patient safety evaluation systems (PSES) and implement comprehensive hospital discharge programs, and requires QHPs to contract with health care providers who implement health care quality improvement mechanisms. In the final rule, hospitals must meet the following criteria:
Due to the recent Supreme Court case, should our hospital hold back events that we report to regulatory agencies such as CDPH, CMS, and accrediting institutions?
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.
Yes, your facility may join more than one PSO and there are benefits to being a part of multiple PSOs. Some provider groups within your facility may belong to a specific PSO such as pediatric anesthesiology PSO. Alignment between specific PSOs may be useful for quality improvement projects.
Those who are a part of the work force at the CHPSO member organization can use PSWP. These are hospital staff including technicians, nurses, and physicians, a well as those who are contractors, including legal counsel. The PSWP can be used for any purpose and it does not have to be de-identified. PSWP can be used across different committees and meetings; however, it cannot be used in a peer review disciplinary hearing.
CHPSO and HCNCC invite you to attend Safe Table Forum in Sacramento, CA on April 19, 2016 from 10:00 a.m. – 1:00 p.m. The topic of discussion is Alarm Management.
Safe tables are meetings held by a PSO to foster frank, privileged discussions around safety events that hospitals face among members belonging to a PSO. Typically, one hospital representative will present a case to the group (e.g., a near miss or a severe harm) and the group is invited to discuss their experiences with a similar event or work through potential causes and identify areas of opportunity.
Data, reports, records, memoranda, analyses or written or oral statements which could improve patient safety, health care quality or outcomes that are specifically assembled for the purpose of reporting to a PSO may be shared with your health care organization’s workforce. Data may be disclosed with your affiliated providers, with your PSO, contractors such as management consultants and legal counsel. Additionally, you can share data with other providers within the same PSO.
Our hospital would like to submit reports to CHPSO, but wish only to submit medication errors. Do all the safety reports have the Patient Safety Work Product (PSWP) privilege?
We suggest that you review the Patient Safety Evaluation System (PSES) templates available to members on the CHPSO website. There are two versions: one concise and one thorough. If you choose to use these templates, we highly advise you review both of them and determine what works best for your facility. The PSES works alongside but does not replace existing policies you may have in place; however, it is possible to include information from existing policies or combine existing policies with the PSES policy.
You may share patient safety work product (PSWP) with health care providers holding privileges at your institution. You can also share PSWP with your workforce, which includes employees, volunteers, trainees, contractors, or other persons whose conduct, in the performance of work for your organization is under your organization’s direct control, whether or not employed by you. These are not considered disclosures under the Patient Safety Act.
A patient safety evaluation system is the system you use to collect, manage, and analyze information (patient safety work product) for reporting to your patient safety organization, CHPSO. There is no one-size-fits-all policy; each health care facility has needs that others may not experience. It is important to keep in mind that the PSES can be an evolutionary document and it is beneficial to revisit it regularly. While most hospitals submit all incident reports and RCAs to CHPSO, some may only report specific event categories.
