How do hospitals know if patient safety incidents that occur within their facility are unique or part of a broader trend?
Before Patient Safety Organizations (PSOs), hospitals couldn’t know if similar patient safety incidents were happening at other organizations – or more importantly – if there was already a solution. Confined by strict patient confidentiality, hospitals had to tread the water of patient safety alone.
“Most of the time, things don’t happen at just one hospital,” says Nina Costilla, RN, MSN, clinical projects manager at THA. “Usually, many hospitals struggle with the same issues. The PSO allows these hospitals to share how they’re dealing with the issue or innovative ideas they might have to address the issue in a safe and secure environment.”
The History and Role of PSOs
The Institute of Medicine’s 1999 seminal report, To Err is Human, highlighted the need to improve patient safety in health care – asserting that bad systems, not bad people, cause medical errors. The report called for a new approach to patient safety, including the creation of organizations that could collect and analyze data on adverse events and near misses, and disseminate the lessons learned from these incidents.
Five years after To Err is Human was published, the Patient Safety and Quality Improvement Act of 2005 (PSQIA) established the legal framework for PSOs in the United States. Under the PSQIA, PSOs are granted federal confidentiality and privilege protections for organizations that share information related to a patient safety event. This protection ensures that providers can freely share information with PSOs without fear of legal repercussions.
Today, there are over 100 PSOs in the U.S., ranging from state-level organizations to national entities that collect, analyze and disseminate information about patient safety incidents, near misses, and adverse events.
A Safe Space for Texas Hospitals
The THA PSO started in 2012 and is federally certified under the U.S. Department of Health and Human Services through the Agency for Healthcare Research and Quality and works with Texas hospitals to improve quality and patient safety. The PSO provides members with access to expert consultation and regulatory updates and networking with clinical peers in other health care organizations.
“The THA PSO is one of the ways that our organization leverages other people to help us make care safer,” says Amber Mann, risk manager at University Medical Center. “Being in a PSO puts me in the same room with like-minded individuals with similar questions, and we all work together to find answers.”
“What’s unique about THA’s PSO is it allows members to tap into the pooled expertise of the larger group,” says Cesar Lopez, J.D., associate general counsel at Texas Hospital Association. “If a hospital is part of THA’s PSO, they have access to THA’s legal team, just like other THA members, which is especially beneficial for small, rural hospitals with little or no legal support and provides that opportunity to discuss issues and potential options for those facilities.”
Currently, there are 100 health care facilities that are part of THA’s PSO, ranging in size from small Critical Access Hospitals to large health care systems. The variety of membership provides a rich environment for shared learning. Participants in THA’s PSO can participate in quarterly safe table meetings where clinicians confidentially report on adverse events, risk analysis, and process improvement ideas.
“The breadth of experience and knowledge is immense when members of the PSO have the opportunity to gather and confer about various quality and patient safety issues,” says Karen Kendrick, RN, MSN, vice president of Quality and Patient Safety.
Another benefit of THA’s PSO, particularly amid a legislative session, are regular legal updates and quarterly calls from THA’s legal counsel that provides members with real-time updates on bills that will impact patients, health care workers and health care delivery.
“We believe that members are our eyes and ears on the frontlines of health care, and we want to be theirs at the Capitol,” says Lopez.
Last week, the THA PSO gathered in Austin for a two-day summit that afforded participants the opportunity to hear from leaders in health law and patient safety. Presentations covered various topics from root cause analysis tools to developing an effective Patient Safety Evaluation System.
“So many of the topics covered reinforce the importance of having policies that support what we do for risk management, how we manage patient safety events and how we protect the organization so we can get more transparent and have open discussions within the organization,” says Misty Woodward, interim director of Risk Management at Hendrick Health.
“Having the veil of a PSO protecting your organization is very important,” says Woodward. “This is what it will take to change health care.”