“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.
We have recently become aware of requests of federal regulators
to review patient
safety work product (PSWP.) This is a good opportunity to
remind CHPSO members of the
parameters governing release of PSWP and additional resources
that may be of use. As you know, documents that a facility
has identified as PSWP as part of their overall patient safety evaluation system policies
and procedures are considered privileged under the Patient Safety
Act.
One of the benefits of belonging to a patient safety organization
(PSO) is the ability of members to be part of a large learning
community. With more than 400 member facilities in 10 states,
CHPSO is able to provide the structure for such a community.
One of the ways that CHPSO facilitates shared learning among its
members is through regular safe table meetings. CHPSO hosts about
22 safe table meetings per year on a wide variety of topics
driven by CHPSO member requests and suggestions, as well as from
patterns observed in the CHPSO database.
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.
