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)
non-binding, non-regulatory guidance that contradicts the
legal positions of AHA, The Joint Commission, CHPSO, and many
“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