FrequentlyAskedQuestions

WhatisaPSO?

PSOsarefederallycertifiedentitiesthatsharethegoalofimprovingthesafetyandqualityofhealthcaredeliverybycollecting,aggregatingandanalyzinghealthcareeventdata(akaPatientSafetyWorkProductorPSWP)withoutthefearoflegaldiscovery,toenabletheidentificationandreductionofpatientandconsumercarerisksandhazards.

DoPSOsreceivefederalfunding?

No,PSOsdonotreceiveanyfederalfunding.CanIjoinmorethanonePSO?

Yes,providersmaybelongtoasmanyPSOsastheywish.PSO’scollaborateratherthancompete.

WhatarethebenefitsofaPSOmembershipandwhyshouldIjoin?WorkingwiththeNCQCPSOoffersmanybenefits,including:• SharedLearning

ThePSOfacilitatesashared-learningapproachatalocal,stateandnationallevelwherehospitalsandproviderscanlearnfromeachother,makefasterimprovementsandreducethecostoflearning.Our“SafeTables”provideauniqueforumthatfacilitatesharedlearninginaprotectedspace.

• PooledexpertiseMemberstapintothecollectiveintelligenceofpatientsafetyexpertsandinnovators,translatingintoexponentialimprovementsclinicallyandeconomically.TheNCQCPSOalsoworkswithstatehospitalassociations,universities,governmentagencies,otherPSOsandqualityandsafetyinstitutesnationwide.

• LegalProtectionsThePatientSafetyActprovidestwotypesofprotection;confidentialityandprivilegeprotections.TheHealthandHumanServicesOfficeofCivilRightsmonitorstheconfidentialityprovisionsandprivilegeprotectionsareenforcedbythejudicialsystem,whichlimitorforbidtheuseofprotectedinformationincriminal,civil,administrativeorotherproceedings.(PatientSafetyRuleSection3.206).

• DataanalysisforpreventionThePSOcollectsdetailedpatientsafetydataunavailablethroughregularpublicchannels.ThisrichdatasetallowsthePSOtoidentifypatternsthatcouldsuggestunderlyingorsystemiccausesofpatientrisksandhazardstopreventtheirfutureoccurrenceandreducepatientharm.

• RegulatoryYourorganizationwillbeeligibletohelpQualifiedHealthPlans(QHPs)meettheAffordableCareActSection1311(h)thatrequiresthemtocontractwithhospitalsthatusepatientsafetyevaluationsystems(PSES)andimplementcomprehensivehospitaldischargeprograms,andtocontractwithhealthcareproviderswhoimplementhealthcarequalityimprovementmechanisms.(PatientProtectionandAffordableCareAct;HHSNoticeofBenefitandPaymentParametersfor2017)

• UniquebenefittosmallhospitalsWeknowstaffinsmallerhospitalsoftenwearmanyhats.WorkingwiththeNCQCPSOhelpssmallerhospitalsdeliverhighqualitycareandmeetregulatoryandaccreditationdemandsbyprovidingoftenneededpatientsafetyandqualityresources.

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WhatspecificprotectionsdoIreceivebybelongingtoaPSO?

ThePatientSafetyandQualityImprovementActof2005(PSQIA),PublicLaw109-41andruleprovideprivilegeandconfidentialityprotectionstospecifictypesofinformationdevelopedwhenaproviderworkswithaPSO,suchasthedatacollectedandreportedtoPSOsbyprovidersandthecommunicationsandfeedbackaproviderreceivesfromthePSO.Subjecttocertainspecificexceptions,thedatareportedtoPSOsmaynotbeusedincriminal,civil,administrative,ordisciplinaryproceedings.(seePatientSafetyRuleSection3.206).(https://www.pso.ahrq.gov/faq#privacy-purpose)

Whatistheimportanceoftheprivacyandconfidentialityprotectionsfordata?Thestrongprivacyandconfidentialityprotectionsareintendedtoencouragegreaterparticipationandrobustdatasubmissionbycreatingapsychologicallyandlegallysafespacetoreportanddiscusssafetyevents.Byestablishingstrongprotections,providersmayengageinmoredetaileddiscussionsaboutthecausesofadverseeventswithoutthefearofliability.Ultimately,participationwillresultinmoreopportunitiestoidentifyandaddressthecausesofadverseevents,therebyimprovingpatientsafetyoverall.

WillPSOactivitiesprohibitpatients,consumersandtheirfamiliesfrombeingabletoseeklegalactionformedicalerrors?

• ThesubmissionofdatatoaPSOdoesnotaffecttheabilityofpatientsortheirfamiliesfromseekinglegalactionifamedicalerrorhasoccurred.

• Atthesametime,datasenttothePSOcannotbedisclosedormadeavailableforlitigationunlessacriminaleventhasoccurred.

Areadverseeventstheonlydataprotectedbylaw?

No.ThePSOcollectsandanalyzesmanytypesofsafetyandqualitydatathatareprotected.Thisprovidesatrueandaccuratepictureofhealthcareatyourinstitution.Anydata,suchasadverseevents,reports,records,memoranda,analyses(suchasrootcauseanalyses),orwrittenororalstatements(orcopiesofanyofthismaterial)whichcouldimprovepatientsafety,healthcarequality,orhealthcareoutcomescanbesubmittedtothePSO.IfthisdataisassembledbyyouforreportingtothePSOanditissubmitted,itisprotected.

Wearenotlookingforlegalprotection.Whyshouldwejoin?• It’sGoodBusiness!ParticipationinanyPSOisvoluntaryanddoneonacontractualbasis.

However,Insurers,qualitygroups,payers,employersandthepubliclookfavorablyonhospitalsandproviderswhoparticipateinPSOactivitiesanddesiretoimprovepatientsafetyandthequalityofhealthcaredelivery.

• Youshouldjoinifyouwanttoimprovethequalityandvalueofhealthcareinthecommunitiesyouserve.TheprimarypurposeofPSOsistoshare,learnandimprovesafety.Thelegalprotectionsaresecondaryandexisttoencourageproviderstoparticipatebycreatinga“safespace”todoso.

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IstheNCQCPSO“listed”byAgencyforHealthcareQualityandResearch(AHRQ)?• Yes.WehavebeencontinuallylistedsinceDecember10,2008.Wewereoneofthefounding

PSOsinthecountry.• AnAHRQlistedPSOhasanofficialsealofapprovalbythefederalgovernment.IfaPSOisnot

listedbyAHRQ,privilegeandconfidentialityprotectionsofthePatientSafetyActwillnotapply.TofindoutifaPSOislisted,visitAHRQ’swebsiteforFederally-ListedPSOs,updatedweekly.https://www.pso.ahrq.gov/listed

HowmanyhealthcareorganizationsparticipateintheNCQCPSO?

112healthcarefacilitiesaremembersoftheNCQCPSO.

Arethereanysmallandruralhealthcarefacilitymembers?

Yes.Thereare15hospitalsunder51beds.

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WhattypesofprovidersareworkingwiththeNCQCPSO?TheNCQCPSOworkswithprovidersacrossthecontinuumofcare:Hospitals,behavioralhealth,ASCs,generalandspecialtymedicaloffices,HomeCareandHospice,andLong-termCare.

DoesthePSOprovidedirectassistancetoitsclientsordoesituseconsultants?

Ourstaffdirectlyworkswithourmembers.Andbeinglocalwecanrespondquickly.Staffwillworkwithyouone-on-onetodeterminethemostsuitableapplicationofPSOservicesforyourorganization.WealsocalluponexternalresourcesfromtheranksofN.Chospitalsanduniversities.Webringinnationallyknownexperts,too,inanefforttoprovideyouwithnewinsightsandideas.

WillthePSOhelpyousetupapatientsafetyevaluationsystem?

ThePSOwillassistyouandprovideyouwithallthenecessaryresourcesandstaffguidancetosetupyourpatientsafetyevaluationsystem(PSES).Weprovideone-on-onesupporttoensureyourPSESmatchesyourorganization’sneeds.

Whatkindofdata/informationiscollectedbytheNCQCPSO?

• TheNCQCPSOcurrentlycollectsdatabasedonAHRQ’s“commonformats”.Adverseeventsincludeoccurrencesthattakeplaceinacute-caresettings,suchasretainedforeignobjectaftersurgery,aswellaseventsthatoccuracrossthecontinuumofcaresuchasfallsandpressureulcers.

• ThePSOcollectsdataon“nearmisses,”whichareeventsthatcouldhavecausedharmbutdonotreachthepatient.

• RootCauseAnalysis(RCAs)arealsocollectedandanalyzed.HowdoesthePSOhandleyourdata?

Inthestrictestofmanner.ThePSOcomplieswithPatientSafetyRulestocollectandcontainsubmitteddatainasafeandsecureenvironment.PoliciesandproceduresthatoutlinethecontainmentoftheCenter’sdataisavailableuponrequest.

DoesthePSOuseAHRQ’sCommonFormats?

Yes.ThePSOcollectsdatausingAHRQ’sCommonFormats.IfAHRQCommonFormatsarenotavailableforaspecificprovidertype,thePSOcreatesacceptableformatsfordatacollectionbasedonmultiplelevelsofinputandindustryanalysis.

HowdoesthePSOcollecteventinformation?

ThePSOemploysasoftwaresystemthatfacilitatessecureelectronicdatatransferfromanyinternaleventreportingsystem.Aplatformisavailabletoallowmanualentryofeventinformation.Ourgoalistomakedatasubmissionhasslefree.

CanIanalyzecomparativedataandcreatereports?

Yes.Oursystemprovidesyouwiththeabilitytoanalyzeandrunyourownreports.Youcancompareyourdatawithaggregateddatasetssuchasstate,nationalandvariouscohorts.

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HowdoIjointheNCQCPSO?

JoiningtheNCQCPSOiseasy.Tostarttheprocesscontactourteambyphoneat919-677-4123,byemailncqc_pso@ncha.orgorcompleteashortformrequestingareturncallfromsomeoneonourteam.

WhatisthecosttojointheNCQCPSO?

AswithmostPSO’s,theNCQCPSOchargesaminimalannualfeetoprovideservicesandsupportstoitsmembers.Organizationspayaflat,perhospitalratewithsubstantialdiscountsgiventohospitalswith50orfewerstaffedbedsandtonon-acutefacilities.Toreceiveapricingquoteforyourorganization,pleasecontactDeanHiggins,DirectorofOperationsat919-677-4212ordhiggins@ncha.org

WhatactivitiesandserviceswillIreceivebybeingaNCQCPSOmember?

Service/Product Description

PSOOperationalSupport • CustomizedassistancesettingupandmaintainingPSOoperationalinfrastructure

• Staffengagementandtrainingatalllevels• AssistwithaddressingbarrierstoactiveandmeaningfulPSO

engagement

SafeTables • Regional,confidentialforumsfocusedontrendingsafetytopics

• Facilitateddiscussionandsharingofbestpracticestoreduceharm

DataReportingandAnalysis

• Secureandautomatedprocessforreportingsafetyevents• State-levelbenchmarking• Federalandstate-levelconfidentialityandprotectionofPSO

data• Analysisandfeedbacktoidentifytrendsandopportunitiesfor

improvement• Ondemandfacilityandsystemlevelreporting

EducationandCollaboration

• Freeanddiscountedwebinars,workshops,andannualconference

• On-demandresourcesandlearningmodules• AccesstootherPSOmembersfornetworkingandshared

learning

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• Patientsafetytrainingandcertificationassistance• Connectiontonationalsafetyexpertsandcollaborative

learningopportunities

PSOMemberNewsletter • Bi-monthlynewsletterhighlightingpatientsafetytopics,bestpractices,andPSOactivities

AlignedNCQualityCenterServices

• PatientandFamilyEngagementfocusedguidance• AccesstoNCQCpatientsafetyandqualityimprovementtools,

resources,andcontentexperts• DiscountsonNCQCpatientsafetyorientedconsultingservices

TolearnmoreabouttheNCQPSOandoureventscheckoutourwebsite

https://www.ncqualitycenter.org/patient-safety-organization-2/