- Patient safety and quality care are at the forefront of discussion in the healthcare industry today. From impact on the patients themselves to the bottom lines for organizations – healthcare organizations and providers are constantly striving towards improving quality of care and patient safety.
There are several practices and processes that can be implemented to drive improvement in these areas, one method in which healthcare organizations and providers are increasingly turning to being patient safety organizations (PSOs).
By January 1, 2017, hospitals with more than 50 beds who want to participate in health insurance exchanges are required to maintain a patient safety evaluation system and PSOs are designed to meet that need.
Patient safety organizations create a secure environment where providers and healthcare organizations can collect, analyze, and share data related to patient safety, adverse events, near-misses, and unsafe conditions.
The data and reporting actions encouraged by PSOs are fundamentally changing how patient safety events are addressed. Providers have traditionally shied away from disclosing errors, but these organizations are designed to combat that by encouraging providers and healthcare organizations to voluntarily report and share data on patient safety events without any fear of legal discovery.
Through streamlined data collection, PSOs encourage and facilitate best practices for improving safety and identifying trends and create a network for participants who have a common shared goal of improving patient safety.
Improving patient safety through a culture of “safe” reporting
Many hospitals and providers are reluctant to share information regarding adverse patient events, near-misses, or unsafe conditions for fear of legal action if those details are discovered. The problem with this underlying fear of reporting events is the missed opportunity to share lessons learned.
Information reported to a PSO is afforded federal privilege and confidentiality protection and is included in a national bank of reported patient safety data. PSOs utilize experts that analyze and aggregate event data locally, regionally, and nationally.
Amy Andres, senior vice president of quality and data at the Ohio Hospital Association, pays close attention to the value of PSOs.
“The value of reporting to a PSO is that events are looked at in a macro cycle as opposed to a micro cycle,” said Andres. “The events are aggregated, research is conducted, information is shared with the members, and the members can implement high-impact strategies.”
Through improved, standardized reporting, PSOs are able to develop insights into the underlying causes of patient safety events and ultimately develop strategies to decrease adverse events in the future. The reporting of near-misses specifically provides the great opportunity to work on solutions without the impact of the event or harm reaching the patient.
Common reporting language improves identification of healthcare trends
Many organizations have structured effective reporting systems that support their own internal analysis of data, but this data cannot be aggregated or compared with similar information from other organizations due to different reporting systems.
PSOs help promote accurate and complete reporting from participants because they are required to use the Agency for Healthcare Research & Quality’s (AHRQ) Common Formats to report data. With a standardized manner of reporting in place, healthcare systems across the nation follow a uniform system for data collection supporting aggregation of data from many organizations and enabling expedited learning among those who participate in PSOs.
With common reporting language in place, there are benefits to PSO participants on local, state, and national levels. Sam Watson, senior vice president of patient safety and quality at the Michigan Health & Hospital Association and executive director of the MHA Keystone Center, explained the benefit of each.
“On a local level, hospitals are able to evaluate near-misses and identify whether ‘good-catches’ are related to system-level concerns or unique outliers, offering the potential to make significant impact on daily practices," Watson said.
"On a state level, PSOs allow for understanding of local challenges and allow hospitals to see how they compare to similar organizations in their area. On a national level, this macro view of the data helps subject matter experts explore and recommend broad-based solutions to improve patient safety and healthcare quality.”
The ability to aggregate data across a larger pool of providers within the network allows the PSO to identify patterns and trends that may not be evident in smaller numbers of organizations or smaller health systems.
The data also enables the detection of serious or rare events sooner. Following analysis of report data, PSOs disseminate information for recommendations, protocols, and best practices based on the data analyzed and current trends in healthcare.
Creating a network with a common goal and “Just Culture”
Healthcare providers often look to further their education in order to improve care quality and safety.
In addition to reporting standards, PSOs offer providers a forum to network with others through user groups, sharing of best practices, access to real-time and customizable reports, tools, publications, alerts, and webinars on patient safety topics as well as critiques of root cause analyses of specific issues – allowing for support and further education.
The ability to network with other members within the PSO is perhaps one of the biggest advantages, as all participants are focused on the common goal of creating safer environments for patients by sharing findings and experience within a Just Culture.
A Just Culture is essential within a health system, as it is an environment that provides accountability not on an individual basis when it comes to errors, but on a system-wide basis. Organizations that implement a Just Culture philosophy encourage transparent reporting and assessment of medical events and are supportive of staff when evaluating errors rather than punitive.
Instead of evaluating an error on outcome, hospitals with a Just Culture look at how the event occurred and asses how it can be prevented and what can be learned from it to prevent it from happening in the future.
With providers focused on improving outcomes, it encourages the shift in thinking from punishing those who make mistakes to creating a forum for open discussions. Watson said that one of the biggest impacts of PSOs is reducing the stigma associated with reporting patient safety events.
The lasting impact on patient safety
PSOs offer information learned through data collection to assist organizations in proactively addressing patient safety issues; and this will have lasting and future impact. PSOs continue to impact the culture of organizations to shift to a team-based approach and lead the initiative to identify and solve problems.
PSOs will continue to drive sharing of information, discussion, and understanding that issues are system-based rather than the fault of an individual. PSOs create an environment where a provider can acknowledge their role in adverse events, discuss these events openly, and work on ways to prevent future adverse events.
Additionally, with federal confidentiality and privilege protections in place, providers will no longer fear that information reported to a PSO will be discoverable.
Organizations will understand the value that benchmarking with other PSO members holds and that the more data contributed to PSOs, the faster national learning will occur to promote widespread change and improvements in healthcare.
This shift will continue to benefit patients, as PSOs support improved safety procedures, improved quality of care, reduced risk from harm and injury, and care aligned around best practices.
Judy Klein, CPHRM, FASHRM is Manager of Risk Management for Coverys, a leading medical professional liability insurance company.