Issuu on Google+

PSONEWS From the Center for Patient Safety

FALL 2013 EDITION

IN THIS EDITION

“Without question there are patients [who] are alive today that got better care , and patients alive today that wouldn’t be alive if it wasn’t for the work of PSOs and their providers.” Dr. William Munier Director of the Center for Quality Improvement and Patient Safety, AHRQ

PSOs collaborate

PSOs Collaborate PSO Protections Readmissions, Safety Culture... Top Six Reasons to Participate National Webinar Series Center Tidbits Small Hospitals: Dilemma Tips for Successful Culture Survey EMS PSO Update PSO Data Snapshot Upcoming Events

1 2 3 4 4 5 6 7 7 8 10

to learn and share

HIT and safety events are ongoing national focus On November 18, 2013, PSO members of the National Alliance of Patient Safety Organizations (PSO) and their members joined the Office of the National Coordinator (ONC) and ECRI for a webinar on health information technology (HIT) and safety events.

The ONC safety and health IT related activities include:

ONC’s message for healthcare providers, professionals, PSOs and vendors included:

• training CMS surveyors about health IT and its quality and safety implications.

• It’s difficult to identify medical errors caused by health IT, including the lack of consistent reporting methods and lack of reporting IT issues because many times IT is an underlying factor that isn’t reported or classified within event reporting systems.

• working with AHRQ to build PSO Common Data Formats into the national health IT strategy for reporting and analysis of health IT-related events.

• implementing the national HIT Safety Policy Framework, with the goal of continually improving health IT which will contribute to safer care.

• releasing SAFER Guides, self-assessment

guides for ambulatory and hospital settings, to assess the safety implications of the use of health IT. • releasing “How to Identify and Address Unsafe Conditions Associated with Health IT” targeted at electronic healthcare record developers, users and PSOs. • report commissioned from The Joint Commission evaluating findings from TJC’s Sentinel Event database (expected January 2014). • potential development of a Health IT Patient Safety Center.

• PSOs play an important role in collecting and analyzing health IT-related events. • Providers are encouraged to report adverse events, near misses and unsafe conditions to their PSO, including any ITrelated issues and information. • Private sector (providers, vendors, PSOs) are encouraged to increase their involvement in its activities, resulting in a move toward higher reliability for health IT.

Did you miss this webinar?

A recording of the presentation is available here. Use password: NAPSO

wwwwww. c . ce en nt e t er fr o f or p r pa at it ei en nt st a s af e f et yt y. o . or g r g

1


CENTER FOR PATIENT SAFETY

PSO PROTECTIONS

NEW TERRITORY FOR DEFENSE ATTORNEYS BY KATHY WIRE, JD, MBA, CPHRM Quality and safety improvement efforts in healthcare have long suffered from participants’ fear that any damaging facts uncovered in investigations would be used by plaintiffs or regulators to punish providers. The Patient Safety and Quality Improvement Act of 2005 (PSQIA) provides strong federal confidentiality and privilege protections for patient safety and quality work, but only if the provider takes the necessary steps. All the state courts applying the law have affirmed its supremacy over state provisions, as long as the providers meet the PSQIA’s procedural requirements. The requirements are flexible, but essential, so here is a quick summary from the implementing regulation... Participation with a Patient Safety Organization (PSO) The PSQIA defines PSOs and requirements that “listed” or “certified” PSOs must satisfy. The Agency for Healthcare Research and Quality (AHRQ) oversees the process. A PSO gathers information confidentially from providers, and then uses aggregated information for patient safety improvements. Almost any licensed healthcare provider can voluntarily participate with one or more PSOs. Patient Safety Evaluation System (PSES) Under the PSQIA, providers define their systems that support reporting to a PSO. A PSES may include event reporting systems, safety and quality committees, performance improvement teams — any part of the organization’s patient safety and quality programs. Some data generated by the PSES must be reported to the PSO, but the scope and nature of reported data can be defined by the PSO and its participants. All of the deliberations and analysis that take place in the PSES are protected under the statute, as is any data reported to the PSO. This protected material is Patient Safety Work Product (PSWP). The Protections PSWP that is generated and managed correctly has full protection from requests, subpoenas or other court orders in litigation or regulatory settings. Under PSQIA, PSWP also acquires confidentiality protections similar to those granted to Protected Health Information (PHI) under the HIPAA and HITECH laws.

2

The provider cannot share PSWP outside its workforce without meeting the very narrow criteria identified in the regulations. The actual changes that result from the work performed pursuant to these provisions (e.g. new policies or changed procedures) cannot be protected. Workforce This is the group of individuals involved in patient safety and quality work who may properly view PSWP under the law. It can include employees, medical staff, consultants, risk management representatives from insurance carriers, or attorneys. Anyone in the workforce with access to PSWP should sign a confidentiality agreement. Lessons Learned The PSQIA creates tremendous opportunities for healthcare providers to deeply explore the safety and quality of their patient care processes without fear of compelled disclosure in litigation or other settings. Counsel should be aware of these protections, but must also know their limitations. Inappropriate efforts to use the protections have already created some confusion and could potentially dilute the strength of this law’s barrier to discovery. The following “lessons learned” come from the cases that have interpreted the law. Information about the cases is available here. • Have policies in place defining your PSES. The law does not require this, but strongly encourages it. The cases interpreting the law have used policy compliance to support a claim of protection. It is harder to protect

work that took place within a poorly defined PSES. • Review the PSES policies with your defense attorneys, so that any discovery responses accurately reflect your structure and workflow. The Center for Patient Safety (CPS) provides its members with a policy template as well as one-on-one assistance with policy development. Contact CPS for info. • With your attorney, confirm that any requested material falls within the scope of your PSES and PSWP. You both must be clear about the workflow that creates the PSWP. Understand WHY the information is PSWP and remember that you need to be comfortable testifying in defense of the protections. • Some providers have a PSO contract but have never reported. Reporting to a PSO is a prerequisite for protections. • Work with your defense attorneys proactively so you can take full advantage of this protected workspace. Kathryn Wire, Principal, Kathryn Wire Risk Strategies, St. Louis, MO and Program Manager/ Long Term Care for the Center for Patient Safety, Jefferson City, MO 1 Public Law 109-41; 42 U.S.C. §6A (VII)(c) (2005) 2 The statute, implementing regulation and other guidance from AHRQ are available at http://www. pso.ahrq.gov/regulations/regulations.htm. 3 42 C.F.R. Part 3 4 73 Fed. Reg. 226, P. 70739 (comments to Final Rule) 5 42 U.S.C. 299b-21 (7); 42 U.S.C. 299(a)-(b) 6 42 C.F.R. Sec 3.20

w w w . c e n t e r f o r p a t i e n t s a f e t y . o r g


FALL 2013

In

h e a lt h c a r e c i rc l e s , h o s p i ta l

re-admissions are on everyone’s mind. Providers are redesigning structures and practices to provide gap-free care to patients as they go from home, to hospital, and back. Payment reform has also brought a new focus on reducing ANY avoidable admission. New incentives drive teamwork at all levels of care in order to give patients what they need, when they need it. Collaboration among providers is more important than ever. The Center for Patient Safety (CPS) can be an important part of that journey.

implemented consistently and reliably. To facilitate that, McGeeney said, a long-term care community needs a strong safety culture. If your home or community is planning to implement INTERACT or another program to reduce avoidable admissions, you might ask these question to see if you have the safety culture in place: How well does your staff communicate? As staff members learn about a new program, does individual learning spread to the larger staff group? How does each staff member reflect his or her accountability for the process? How are speed bumps turned into broad learning?

RE-ADMISSIONS,

SAFETY

Healthcare providers from throughout the continuum of care met in the Kansas City area on October 24 to deepen their understanding of avoidable hospital admissions. Sponsored by Primaris, the session focused on efforts to eliminate gaps between locations and levels of care. Speakers from Primaris and the Kansas City-area Community Based Care Transitions Program (CCTP) described the multiple programs available to providers to improve transitions into and out of hospital care. Participants from hospitals, home health agencies, medical clinics and long-term care facilities worked in small groups to identify root causes of re-admissions, finding common understanding and easy agreement about issues that increase avoidable admissions. Common themes emerged around communication, teamwork and reliability — all attributes that grow out of a strong safety culture.

CULTURE and

PSO-PROTECTED

Center for Patient Safety Can Help The Center’s LTC program offers the Survey of Resident Safety Culture, which can identify strengths and weaknesses in a home’s communication, teamwork and learning environment. Just Culture™ helps leaders identify how they can improve systems and individual behavioral choices to make programs like INTERACT more effective. A Safe Space for Collaboration

Any effort to reduce admissions (especially re-admissions) requires close work between providers at every level. Safety and quality improvement depends on the provider’s ability to explore both strengths and weaknesses of its current processes. Yet providers often fear discussing their institutional weaknesses with “outsiders” may put them at risk of litigation or regulation.

COLLABORATION

Developing the Right Culture The afternoon moderator, Primaris’ Kent McGeeney, described “Interventions to Reduce Acute Care Transfers,” or INTERACT, a powerful set of tools developed by Florida Atlantic University for long-term care providers. The tools, available at no cost from the INTERACT website, help identify key data points, guide discussions and provide a structure to address issues around transfers. However, they only work if the staff has the right conversations, works together to efficiently address all necessary issues, and they must be

Providers who participate with a Patient Safety Organization can hold these discussions in a space with full federal confidentiality protection. The CPS has already worked with EMS providers and their regional hospital partners to set up structures for confidential QA/PI discussions. We can do the same for hospitals, nursing homes, transport companies and outpatient providers. Any licensed healthcare provider can participate with a Patient Safety Organization. For many Missouri providers, the cost of their participation can be subsidized or provided for free. For more information about any of these programs, or to participate, see www.centerforpatientsafety.org/ltc.

Have you noticed this icon?

Look for this icon to find additional resources in the articles. You’ll find links to downloadable templates, websites and other resources. Available in the electronic version of this newsletter.

w w w . c e n t e r f o r p a t i e n t s a f e t y . o r g

3


CENTER FOR PATIENT SAFETY

TOP6

SIX REASONS TO PARTICIPATE IN A PSO Ever wonder why healthcare providers should participate in a Patient Safety Organization (PSO)? Here are six good reasons: 1. Participate in sharing and learning aimed at preventing medical errors and patient harm. 2. Collaborate with other providers to identify medical error prevention strategies. 3. Gain the support and expertise of PSOs to enhance quality and safety processes and practices. 4. Gain federal protections that fill the gaps left from peer review and attorney-client privilege protections. 5. Meet the Accountable Care Act requirement. 6. PSO participation as a hedge against onerous state-mandated reporting legislation. The Center for Patient Safety offers PSO services for hospitals, ambulatory surgery centers, emergency medical services, and long-term care. Contact the Center for more information.

“Get involved with your PSO if you aren’t already. PSO are the wave of the future , they are part of the future , clinically, electronically and as part of quality and safety improvements.” Dr. William Munier

Director of the Center for Quality Improvement and Patient Safety, AHRQ

“I think with the traction that we have in the patient safety protected work space , PSOs represent the best game in town for meaningful improvement in quality and safety.” Dr. William Munier

Director of the Center for Quality Improvement and Patient Safety, AHRQ

4

NATIONAL WEBINAR SERIES Do you have questions about Patient Safety Organizations? The Center for Patient Safety (CPS) partnered with VergeSolutions to offer a series of three national PSO webinars explaining the value of PSO participation. Presenters provided tips on how to define your patient safety evaluation system (PSES) and patient safety work product (PSWP), as well as your workforce. Part I - Watch video/audio or download the slide deck We know hospitals are asking how to establish a PSES and define PSWP to gain the most from the federal protections and improvement opportunities available by working with a Patient Safety Organization (PSO). During the webinar, CPS answers questions about establishing a PSES and reporting PSWP to a PSO. Part II - Watch video/audio or download the slide deck Building upon Part I of the series, Part II answers more questions about establishing a PSES and delves into PSWP, how to establish a PSO Workgroup and how to define your Workforce to gain the most out of PSO participation. In addition, a summary is included of court cases to-date that have supported use of the federal PSO protections for quality and safety work product. Part III - Watch video/audio or download the slide deck Part III features the following industry experts from the Agency for Healthcare Research and Quality (AHRQ), discussing PSOs as part of the current federal, state and compliance landscape: •

Dr. William Munier, Director of the Center for Quality Improvement and Patient Safety, AHRQ

Diane Cousins, PSO Operations Lead for AHRQ

National PSO Landscape and Horizon The third webinar showcased Dr. William Munier, Director of the Center for Quality Improvement and Patient Safety for the Agency for Healthcare Research and Quality. He provided an update on the national PSO scene, indicating that 4,602 healthcare providers have a signed contract with one of the 76 certified PSOs. Three have sent data to the Privacy Protection Center (PPC) for transmission to the Network of Patient Safety Databases (NPSD). Dr. Munier reported that the common data formats are the foundation of ongoing research to further patient safety. The goal: extracting information from the electronic medical record, thus eliminating the burden of data input by providers. The Office of the National Coordinator (ONC) is soliciting active participation and input from PSOs in various projects to expand knowledge about types and rates of HIT-related adverse events. PSWP and the CMS QAPI Program Finally, Dr. Munier updated the ongoing discussions between AHRQ and CMS to resolve the issue of CMS surveyors asking providers for PSWP. The Joint Commission and the American Hospital Association have joined PSOs across the country in providing information. Both AHRQ and CMS realize this conflict “needs to be solved urgently.” No projected completion date was provided.

w w w . c e n t e r f o r p a t i e n t s a f e t y . o r g


FALL 2013

Did You Know

If you are interested in receiving the latest news and information from the Center, click here to subscribe and receive updates direct to your Inbox.

Center Tidbits International Standards for Tubing Connections An international effort by governmental, professional, and trade organizations along with medical device and product manufacturers is underway to develop standards requiring the design of tubing connectors so only devices that should be connected are able to be connected and those devices that should not be connected are incompatible. Work is being completed for enteral applications, which are expected to reach the market as early as 4th Quarter 2014. Each additional standard will focus on connectors for a specific device category and will be released as it is completed. Details of the design work and Frequently Asked Questions are available here.

Great to see CPS PSO Participants at the MHA Convention & Trade Show Thanks to those of you that dropped by our booth at the MHA Convention & Trade Show. It is always great to see and talk with our PSO participants!

CPS PSO Hosts Booth at American Ambulance Association Annual Convention Carol Hafley and Jason White hosted a booth for the Center for Patient Safety recently at the American Ambulance Association Annual Convention in Las Vegas, Nevada. The interest by ambulance services in participation in a PSO is growing nationally as a result of the ground-breaking work in Missouri.

Certificates Available (CPS Members only)

Each PSO member can print a certificate that recognizes its participation with the Center for Patient Safety (CPS). Just answer a few questions to confirm your participation and you’ll receive immediate access to a printable certificate. Complete the PSO Participation Validation survey.

ShareSuite (CPS Members only)

Reminder: training videos and a User’s Guide are available online, or contact the Center with any questions or concerns.

(Center Tidbits continued on page 9)

PSO ALERT!

PSO ALERT: Left Behind… Retained Surgical Items The Joint Commission recently released Sentinel Event Alert, Issue 51: Preventing Retained Surgical Items (RSI). This alert reflects data about events the Center for Patient Safety (CPS) is receiving as well. As a Patient Safety Organization (PSO), CPS collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including retained surgical items. RSIs are unintentionally retained objects from an invasive procedure. While RSI events do not occur often, they still happen. In cases of RSIs, the item is often discovered and removed right away. However, this requires additional surgical procedures, can cause the patient undue strain and may extend their recovery time. PSO data reveals the most often reported retained items are sponges and guide wires, but other cases include broken surgical items like drill bits, and parts of instruments and devices. Multiple practices can reduce the potential for RSIs. Note that no single intervention will work as well as the introduction of several that function as backups for one another. For example, CPS PSO data suggests there is a high reliance on using a system of counting, however, this procedure does not catch broken items or miscounts. The Center supports The Joint Commission’s recommendations: 1. Develop a reliable and standardized counting system 2. Develop a wound opening and closing procedure 3. Perform intra-operative radiographs when there is a discrepancy in the surgical item count 4. Promote effective communication 5. Document discrepancies 6. Incorporate technology when possible Read the Center for Patient Safety PSONews article “Left Behind… Surgical Bits and Pieces” from the Winter 2013 newsletter. Find out more about the alert from The Joint Commission.

w w w . c e n t e r f o r p a t i e n t s a f e t y . o r g

5


CENTER FOR PATIENT SAFETY

Small hospitals’

Dilemma:

No Time or Resources for Patient Safety Healthcare reimbursements are decreasing and provider requirements and expectations are increasing — a familiar dilemma facing hospitals across the United States. But that dilemma is especially daunting for small hospitals. Is patient safety being left behind in the wake of pressures that include scrutiny from regulatory and accreditation surveys; increased resources required for mandatory reporting; improvement projects such as Hospital Engagement Network participation; meeting meaningful use requirements; and higher expectations from patients and families?

process changes were key to changing their culture: the patient safety culture survey and an empowered safety team with executive leader support. Royal Oaks uses the results of the patient safety culture survey to help identify areas of greatest opportunity and to measure their progress. Formation and empowerment of a multi-disciplinary Safety Team has brought patient safety front and center across the organization. Department representatives, identified by the green safety lanyards they wear, bring safety issues they hear from the front-line staff to the committee to discuss and plan improvements. If the committee can implement the improvements on its own, the members “just do it.” Suggestions that require CQI teams or administrative decisions are forwarded to the administrative team.

For small hospitals, having fewer patients means they do not experience a sufficient volume of “never events,” complicating their ability to have reliable safety measures. They struggle to find the means to purchase the technology or resources to implement patient safety practices such as bar-code systems for medication and patient identification or intensive medical record review. All of this adds up to an enormous challenge for small hospitals today. Where to Start? Royal Oaks Hospital, a 41-bed behavioral healthcare facility in Windsor, Missouri, located between the Lake of the Ozarks and Highway 70, provides mental healthcare for children, adolescents and adults. Its small size has not stopped the patient safety improvement efforts. Saundra Overton, RN, BC, Chief Nursing Officer, Director of Continuous Quality Improvement, refuses to let financial and resource challenges stand in the way of consistently providing safe care for every patient. The mantra of the leadership team is that “focus on patient safety is not an option.”

Department safety representatives designated with green safety lanyards.

Royal Oaks’ improvement journey began about two years ago with the knowledge that it takes a long time to change culture. Two

The Key to Success? Employees see action and support by the leadership team and therefore willingly report additional safety issues. Early on, most of the reported issues involved employee concerns, rather than patient safety issues. However, with increased patient safety education, improved communication and action on the part of the administrative team, employees recognize and appreciate the renewed focus on patient safety. The positive attitude became contagious. To improve communication, department safety bulletin boards and a quarterly Safety Newsletter highlight the ongoing changes, with a message

from senior leaders: “You spoke, we listened and took action.” With increased trust came increased event reporting — another trait of a high-performing hospital focused on improving patient safety. Employees are learning the importance of taking time to report events and near misses, as they know their leadership team will respond. Making it Better As a provider of mental healthcare, Royal Oaks’ greatest patient safety concern is a safe environment to prevent patient harm, especially suicide. They implemented two major changes. The first involved improving their patient risk-assessment form, using one from Loma Linda University. The previous suicide riskassessment consisted of questions that assessed suicide thoughts and intent. The revised assessment determines methods and means along with intent so staff can quickly and effectively identify patients at risk for suicide and provide a safe care environment. The second change, involved improving environmental safety, following the Veteran’s Administration assessment form. Changes included adding additional security cameras and safety alert mechanisms for staff, as well as “suicide-prevention” faucets, safe doors in the patient rooms, and renovating the admission area to provide a safe holding place for new admissions. The Journey Continues While Royal Oaks also faces the challenges of decreased reimbursement and increased expectations, administrators are committed to keeping their focus on patient safety. It’s not an option in their culture – it’s there to stay! “It’s as simple as the golden rule,” said Administrator Jon Bair. “We want to treat patient safety concerns as we would want to be treated in the same situation.”

Have you noticed this icon?

Look for this icon to find additional resources in the articles. You’ll find links to downloadable templates, websites and other resources. Available in the electronic version of this newsletter.

6

w w w . c e n t e r f o r p a t i e n t s a f e t y . o r g


FALL 2013

A culture of safety and PSO services continue to expand in EMS The Center is thrilled to report we have reached 100 agencies participating in the EMS PSO! The Center would like to thank all of the hospitals with ambulance services that include their EMS line of business in their work with the PSO. We also have received 75 EMS event reports to date, and data continues to be entered. We continue to work with all of our EMS participants to ensure they are taking full advantage of our PSO offerings. On the national front, the final document for the Strategy for a National EMS Culture of Safety has been published, outlining recommendations to be taken by EMS agencies, providers of care, and national EMS associations, to name a few. Some recommendations are: • Collaborate with EMS personnel in the development, promotion and implementation of a comprehensive system-wide safety program for their EMS system, such as Just Culture or other similar programs; and make EMS safety a corporate value.

• Promote the need for coordination of all EMS safety-related programs at the local, regional, state and federal levels and integrate these into the agency’s Scope of Practice. • Support new educational safety initiatives within initial EMS education curriculum and through other certification courses such as NAEMT’s EMS Safety Course. • Promote the development of new and improved safety standards that affect all aspects of the EMS system based on best practices and successful safety programs. • Support the creation of a national EMS safety data system that collects both patient and EMS personnel data. The Center was also proud and honored to present a three-part webinar series this fall for the American Ambulance Association titled, “Connecting the Dots – What a Culture of Safety and Patient Safety Organizations Mean to Quality and Safety Improvements in EMS.” Series topics

included the importance of establishing a safety culture to promote error and near-miss reporting; how the PSO protections work and how to operationalize them within an EMS agency; and stories from current EMS participating agencies. CPS gives special thanks to Jason Shearer (Kansas City Fire EMS), Mike Wallace (Central Jackson County Fire EMS), and Jason White for sharing their stories during the final session. Additionally, CPS again hosted a vendor booth at the American Ambulance Association’s annual convention and trade show in Las Vegas, Nevada, to continue promoting valuable EMS PSO services and the great innovations within EMS agencies. Stay tuned for more in 2014! For the most recent information on our EMS work, checkout EMS PSONews!

TIPS for a SUCCESSFUL SURVEY on PATIENT SAFETY CULTURE The Agency for Healthcare Research & Quality’s (AHRQ) in-depth study of how to format, word, and categorize survey questions has resulted in a highly reliable resource that can provide a detailed analysis of your patient safety culture. The results of a good survey can provide evidence of cultural improvements and locate areas of cultural weakness in many healthcarerelated organizations. AHRQ offers a national benchmarking database so you can see how your survey results measure up.

But all too often, surveys are distributed, results are collected, and then…nothing happens. Staff quickly recognize when they are asked for feedback, but don’t see results. If you’ve offered a survey at your facility, make the most of it by following these tips: 1.

Pre-survey: Plan in advance! Time your survey so it doesn’t overlap other questionnaires, such as employee satisfaction surveys. Offer an incentive to complete the survey. Cookies or a drink from the cafeteria go a long way!

If you have a larger budget, you may choose to offer a drawing for those who complete the survey. Some organizations offer iPads, iPods, Kindles, gift cards or similar incentives. But don’t feel you have to spend a lot money to drive up your response rates. Be creative! Remember, the more responses you receive, the better the results will reflect your actual culture. Harness the competitive spirit and reward departments that reach their goals by offering unit-wide pizza parties. And don’t forget your weekend and night staff!

2.

Build the excitement before and during the survey period! Send emails, hang posters, promote the survey on your intranet site, tell staff in meetings, huddles, and when you pass them in the hallway. Promote and encourage anonymity for their honest feedback and participation in the survey process. Let staff know when and why you are asking for their input — and let them know what they can expect after the

survey is over, such as the coordination of improvement teams and action plans. It may seem like a lot, but trying even a few of these ideas will lead to higher response rates and, as a result, more accurately reflect the culture in your organization.

3.

Post-survey: Don’t limit the survey to distribution and collection only! The key to a successful survey is a solid post-survey process. Include six to eight weeks after the survey ends to review the survey responses, create action plans with teams, roll-out improvements and share the changes with staff. Your organization will not only benefit from the increased focus on patient quality and safety, but your staff will appreciate that you’ve listened to them.

The Center for Patient Safety fully supports and encourages the use of the Survey on Patient Safety Culture. In fact, we encourage it so much that we offer a full line of our services to promote, administer and analyze the survey and your results. Want to learn more? Visit us online.

w w w . c e n t e r f o r p a t i e n t s a f e t y . o r g

7


CENTER FOR PATIENT SAFETY

PSODATA

snapshot Data continues to pour in to the Center’s PSO database. In the four-quarter period from October 1, 2012 to September 30, 2013, the Center received nearly 3000 events including incidents, near misses, and unsafe conditions. While 95% of the events received were incidents, it is important to note that the lessons learned from analyzing patient safety events that do not reach the patient (near misses and unsafe conditions) are just as important as analyzing the information about events that did reach the patient. In the most recent four quarter period, falls were the most often reported event with medication or other substance events following closely behind. The same period’s data includes 18 deaths reported (graphic at right) and 23 severe/permanent harm. Eight of the deaths were related to a healthcare-associated infection. Of the 23 severe/permanent harm, ten were related to falls. The Center for Patient Safety strongly encourages you to report your events to a Patient Safety Organization. IMPORTANT NOTE: The deidentified data that makes up this report was obtained from the Center’s PSO database using the following criteria: 1) events were entered into the database with Initial Report Dates between October 1, 2012 and September 30, 2013 and 2) events were submitted to the PSO. REMINDER: PSO adverse event reporting cannot be used for comparison of individual organizations. The purpose of PSO adverse event reporting is to learn what events occur and why, and to use that information to prevent future occurrence and patient harm. The value is in the quantity, quality, and details! The more reports obtained by the PSO containing detailed information about errors, near misses, and unsafe conditions, the greater potential for learning, sharing ,and proactively preventing future harm, costs, and liability exposure.

8

Did You Know

Interested in receiving more information about PSO services available to you? Visit our website at www.centerforpatientsafety.org

w w w . c e n t e r f o r p a t i e n t s a f e t y . o r g


FALL 2013

“I can’t think of a better way to move forward in the world of [patient] safety than working with your PSO.” Dr. William Munier

Director of the Center for Quality Improvement and Patient Safety, AHRQ

CENTER TIDBITS

(continued from page 5)

HHS issues proposed rule regarding the ACA PSO reporting requirement A proposed rule implementing several provisions of the Affordable Care Act (ACA) has been issued for comment through December 26th. The proposed rule, beginning on page 171, addresses the ACA’s requirement for hospitals to meet patient safety and quality improvement requirements in order to be eligible to contract with a qualified health plan that participates in the new health insurance exchanges. As initially written, Section 1311 of the ACA included a provision requiring hospitals with more than 50 beds, by January 2015, to meet certain patient safety requirements, including using a patient safety evaluation system (PSES). The newly proposed rule clarifies that a PSES is the collection, management or analysis of information for reporting to or by a patient safety organization (PSO). However, the Centers for Medicare & Medicaid also indicate, within the proposed rule, they intend to delay the PSO participation requirement due to several challenges with the 2015 deadline. Beginning in 2015, hospitals will be required to meet current CMS requirements for patient safety and quality improvement while CMS develops further regulation for implementation of the patient safety provisions over the next two years. Comments on the proposed rule are due December 26, 2013.

Be a Safety Sponsor: How you can help! The Center for Patient Safety values partnerships with organizations and individuals who want to support improvement in healthcare quality and patient safety. Because the Center is a not-for-profit organization, donations are tax-deductible. There are three ways to join the effort to spread safety culture throughout the healthcare community: individual donation, organizational sponsorship levels, and/or supporters can sponsor an event or initiative. Opportunities include: • Education and training activities • Patient Safety Awareness Month activities and events • Clinical collaboration • Surveys, analysis, and reports • Adverse event reporting system • Research and analysis • Publications and reports The Center makes the process easy; you can donate online in minutes. And, of course, any of the Center staff can answer your questions and provide more information.

In partnership with the National Patient Safety Foundation-

The Center for Patient Safety is now offering a special 10% discount on membership in the American Society of

Professionals in Patient Safety New Online Curriculum and Professional Certification also available

• 10% discount on first year membership in the American Society of Professionals in Patient Safety (ASPPS) • $200 discount for National Patient Safety Foundation (NPSF) • Online Patient Safety Curriculum (including available CE & CME) • $50 discount toward certification from the Certification Board for Professionals in Patient Safety Visit www.centerforpatientsafety.org for more information. • And much more! 9


CENTER FOR PATIENT SAFETY

UPCOMING EVENTS..

Did You Know

Interested in getting regular updates from the Center? Follow us on Twitter @ PtSafetyExpert.

2014 January 29 - PSO Advisory Committee March 21 - 8th Annual CPS Patient Safety Conference ST. LOUIS, MISSOURI

April 29, 2014 - PSO Day (MEMBERS-ONLY) COLUMBIA, MISSOURI

FOR MORE INFORMATION, CONTACT ANY MEMBER OF OUR PSO TEAM Executive Director, BECKY MILLER, MHA CPHQ, FACHE, CPPS bmiller@mocps.org Assistant Director, CAROL HAFLEY, MHA, BSN, RN, FACHE chafley@mocps.org Patient Safety Specialist, EUNICE HALVERSON, MA ehalverson@mocps.org Project Manager, KATHRYN WIRE, JD, MBA, CPHRM kwire@mocps.org Program Manager and Analyst, ALEX CHRISTGEN achristgen@mocps.org Medical Director, MICHAEL HANDLER, MD, MMM, FACPE Contractor, AMY VOGELSMEIER, PHD, RN, GCNS-BC

For additional information on the Center’s PSO activities, resources, toolkits, upcoming events, safety culture resources, and more, visit our website at www.centerforpatientsafety.org or follow us on Twitter @PtSafetyExpert for the most up-to-date news.

NOTE

Some articles contained within this newsletter may reference materials available to Center for Patient Safety PSO participants only. If you have questions about any Center-resources or articles within this newsletter, please contact the Center for Patient Safety at info@mocps.org or call our office at 888.935.8272. The information obtained in this publication is for informational purposes only and does not constitute legal, financial, or other professional advice. The Center for Patient Safety does not take any responsibility for the content of information contained at links of third-party Websites.

ABOUT THE CENTER: The Missouri Center for Patient Safety, dba Center for Patient Safety, was founded by the Missouri Hospital Association, Missouri State Medical Association and Primaris as a private, non-profit corporation to serve as a leader to fulfill its vision of a healthcare environment safe for all patients and healthcare providers, in all processes, all the time.

10

w w w . c e n t e r f o r p a t i e n t s a f e t y . o r g


PSONews Fall 2013 Edition