Patient Safety Evaluation System (PSES) Policy Templates

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.

To ensure that both new and established members have PSES policies that are robust and compliant with all requirements, CHPSO is partnering with the Alliance for Quality Improvement and Patient Safety (AQIPS) to provide updated PSES templates and several educational offerings designed to assist your organizations in the review and/or development of your PSES. The new templates will be made available prior to the first in a series of related educational offerings.

The draft PSES templates will provide you with a starting point to facilitate your efforts in the development a robust PSES. These templates are being used in hospitals and other healthcare facilities across the country. Proper customization and implementation of these templates will make it easy for your organization to create privileged Patient Safety Work Product (PSWP). Please note that the templates will need to be modified to address the specific requirements of CHPSO and your organization’s internal innovative quality improvement programs.   

We would like to encourage all CHPSO members to review their current PSES policies and then join us for the following webinars.

During these webinars we will share insights into how these systems have been designed, implemented and improved upon by others and take a deeper dive into the legal underpinnings of a PSES. Click here to view all of our upcoming webinars. Please note that while we can assist you in designing a PSES to flow into your current programs, CHPSO takes on no legal responsibilities for your PSES and has no legal duty to defend your privileged PSWP.

“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 All inquirers will remain anonymous.