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Ask CHPSO

Overview

Ask CHPSO

October 15, 2013

“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.

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Ask CHPSO

Patient Safety Evaluation System (PSES) Policy Templates

August 28, 2019

Participation in a Patient Safety Organization (PSO), such as CHPSO, requires that organizations develop and maintain a Patient Safety Evaluation System (PSES). The organization’s PSES provides the structure and the processes which allow the organization to conduct patient safety and quality improvement activities without fear of litigation, professional sanctions, or injury to professional reputation. However, these privileges and protections rely on the proper design and implementation of the PSES.

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Ask CHPSO

Patient Safety Work Product in a Non-Event Domain

August 27, 2019

A primary benefit of belonging to a patient safety organization (PSO) is the protection afforded to the member organization regarding patient safety work product (PSWP). CHPSO is a federally listed PSO under the Patient Safety and Quality Improvement Act of 2005 (PSQIA) and therefore:

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Ask CHPSO

Ask CHPSO: Handling Requests for Disclosure of Patient Safety Work Product

April 2, 2019

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.

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Ask CHPSO

What is a CHPSO Safe Table Forum?

April 1, 2019

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.

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Ask CHPSO

What is Patient Safety Evaluation System and How Long Should we Retain Patient Safety Work Product?

February 5, 2019

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.

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Ask CHPSO

What do I need to report to CHPSO?

February 2, 2018

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.

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Ask CHPSO

How Much Does it Cost to Join CHPSO?

December 4, 2017

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.

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Ask CHPSO

Why join CHPSO?

October 3, 2017

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.

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Ask CHPSO

Can we submit personnel-related events or peer-review events to CHPSO?

May 30, 2017

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.

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Ask CHPSO

If my hospital is part of a HIIN, do I have to submit data to a PSO?

April 7, 2017

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.

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Ask CHPSO

Can we join CHPSO even though our hospital is not in California? Does our hospital have to join a PSO?

January 30, 2017

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.

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Ask CHPSO

How Long Should We Retain Patient Safety Work Product?

December 1, 2016

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:

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Ask CHPSO

Does our hospital have to submit event report data to the PSO by January 1, 2017?
From C.W., a hospital in San Diego County

September 30, 2016

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:

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Ask CHPSO

Ask CHPSO: Due to the recent Supreme Court case…
A.Q. – From a San Diego Hospital

August 11, 2016

Dear CHPSO,

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.

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Ask CHPSO

Can our hospital belong to more than one PSO?
C.S., from a Northern California hospital

June 10, 2016

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.

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Ask CHPSO

Who May Use PSWP in Our Organization?
— E.D., from a hospital in Northern California

April 13, 2016

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. 

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Post

Upcoming Member only CHPSO Safe Table Forum
The topic of discussion is Alarm Management.

April 13, 2016

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.

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Post

ASK CHPSO
What is a safe table? -K.D., from a hospital in Southern California

February 8, 2016

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.

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Ask CHPSO

Ask CHPSO: What and with whom can we share our event reports?
–E.K. -A Bay Area hospital

October 2, 2015

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.

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Ask CHPSO

PSWP Privilege: Submitting a Subset of Reports
-G.B. A hospital in Texas

August 5, 2015

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?  

Dear G.B.,

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