What is a Patient Safety Organization and Should You Join One?
By Brenda Giordano, RN, MN
Can they really say that?
In 2011, the government asked Walgreens for information about two of its pharmacists. Walgreens said “no” to the request. There was nothing the government could do about it — Walgreens belonged to a Patient Safety Organization (PSO).
If you are a provider and are unfamiliar with PSOs, take six minutes to read this article. You’ll not only learn how to have a more just and fair culture of safety, but also how to have stronger legal protections for the work your teams do with safety events.
Nine years ago this July, Congress passed the Patient Safety and Quality Improvement Act of 2005, also called the Patient Safety Act. This law created a system of voluntary reporting to Patient Safety Organizations (PSOs) of safety events, near misses, and unsafe conditions, similar to what is available within aviation. At the same time, a Network of Patient Safety Databases (NPSD) was established so data could be analyzed and we could all learn why safety events occur and how to avoid them.
The ultimate aim is to improve safety, but in a manner that also creates environments where working through the nitty gritty of what happened and why it happened can be done with legal protection and confidentiality. This freedom to fully explore safety events and safety data should foster a Just Culture, where reporting an event does not result in punishment, but rather in learning.
Let me take a pause here to lay this out very plainly. Provider organizations (hospitals, skilled nursing facilities, pharmacies, home health, ambulatory care, physician and dentist offices, laboratories, renal centers, ambulance and paramedic services, and so forth) can receive legal protections from discovery in the case of a civil law suit if they belong to a PSO and put together a Patient Safety Evaluation System. This means that if, heaven forbid, you, as a provider find yourself being sued, there are strict limits on what can be “discovered” (think “uncovered.”)
Two things can be discovered: the facts of the case (what is in the medical record) and the billing and discharge information. Everything else — with exceptions that make sense, like the committee meetings where specific safety events are discussed or the information gained from root cause analysis – is legally protected.
If you hang around a hospital, clinic, or any of the above-mentioned care areas, you probably know that after an event, the Risk people often rush in and tie people’s hands on what is documented. They are afraid that a lawsuit will uncover all kinds of things that the facility would be liable for, that would make them look bad, or that would hurt their reputation.
This is a logical approach, but sometimes the end result is that few things are learned and progress on safety is slow since everyone’s mode is CYA (the only acronym I decided to not spell out). I really wish it was not like this because I truly believe that complete transparency is the better road to take.
The reality is that few organizations have the guts to be fully transparent. The legal protection provided by this law tries to break up that bad cycle of “burying our mistakes” and remove the fear so that honest work on safety improvement can happen.
Comparative information in safety is hard to obtain. To that end, the Agency for Healthcare Research and Quality (AHRQ) created a common format so that event information from any safety reporting system can be placed into 10 categories. Research can then be done on falls, medication errors and so forth. PSOs send de-identified information to AHRQ in this common format for addition to the Network of Patient Safety Databases.
Here are few reasons for joining a PSO.
- It encourages a healthy culture of safety. It’s hard to learn when you are worried that you’ll be punished or found out in a public way. A PSO helps to remove the “‘whack of the ruler across the knuckles” attitude that does not help anything. The intent of the law is to foster learning, not place blame. We all want to improve safety and quality for our patients. A healthy Just Culture of safety can foster this.
- Do it while it’s voluntary (unless you have really bad readmission.) Joining a PSO is voluntary, but in the future, hospitals with 50 beds or more need to have a Patient Safety Evaluation System in place to participate in state insurance exchanges (the exact date is not set). By joining a PSO now, hospitals can be prepared for this eventuality with a good system in place. No one knows if the PSO program will ever be mandatory, but knowing the government… About the readmission exception, courtesy of the Affordable Care Act, if the Secretary of HHS has determined you are eligible, well, you probably know who you are and why you need to be part of a PSO.
- Remove wasteful costs that come with poor safety. Safety-related lawsuits are costly to defend. In addition, liability carriers increase premiums when they have to defend you a lot. Imagine having your carrier tell you, “Your premiums will be going down because we’ve had so few cases where we needed to defend you.” Wouldn’t that be nice?
- Compare and collaborate with other organizations. PSOs can provide de-identified regional and national safety benchmarks. Knowing where you stand can help you to focus your improvement efforts and where to give praise. PSOs can also broker collaboration among their members so they can share what they have learned. It’s great to have a buddy outside your own system where mutual learning is not just allowed, but encouraged.
There are around 80 PSOs. Some are specialty based, others are state based, and many will cover multiple types of providers across the US. I hope you will consider joining one.
Brenda Giordano, RN, MN is operations manager of the Quantros Patient Safety Center, a federally-listed PSO serving 4,000 facilities, of Milpitas, CA.