patient safety and quality improvement act powerpoint

OCR is responsible for the investigation and enforcement of the confidentiality provisions of thePatient Safety Rule. This includes periods when a PSO is not collecting or analyzing patient safety work product. When applied conscientiously, an ISO management system will provide a framework for improvement efforts and the discipline to demonstrate outcomes. Is a PSO required to meet the appropriately qualified workforce requirement when a PSO is not collecting or analyzing patient safety work product? For more information on the Act and how organizations can become PSOs, go to the Web site:https://pso.ahrq.gov. PSOs can receive reports on quality and safety from any health care provider, including hospitals, doctors' offices, nursing homes, and ambulatory surgery centers. HHS 13-PS-018, illustrates how information can flow between a provider and its PSO-primarily, between the provider's patient safety evaluation system (PSES) and the PSES of the PSO. Preventable Tragedies: Superbugs and How Ineffective Monitoring of Medical Device Safety Fails Patients. There are eight patient safety activities that are carried out by, or on behalf of a PSO, or a healthcare provider: The term "safety" refers to reducing risk from harm and injury, while the term "quality" suggests striving for excellence and value. When is an individual considered a member of a PSO's workforce? Clipping is a handy way to collect important slides you want to go back to later. View them by specific areas by clicking here. PPT - QUALITY IMPROVEMENT AND PATIENT SAFETY PowerPoint presentation https://pso.ahrq.gov/faq, 5600 Fishers Lane 03/15/12 NNLM Representative {Frankel} - More and more hospitals are including patient representatives on committees, boards and even rounds. As the lead Federal agency for patient safety research, AHRQ is an appropriate partner for PSOs and healthcare providers. AHRQ refines existing Common Formats and considers new types for development on an ongoing basis. Weve learned a lot along the way, and put those lessons into practice. Patient Safety and Quality Improvement Act of 2005. | PSNet Part 3). There is also a CFER designed for community pharmacies (CFER-CP) and development of a CFER for Diagnostic Safety (CFER-DS) is underway. By addressing common, preventable adverse events, a healthcare setting can become safer, thereby enhancing the quality of care delivered. To sign up for updates or to access your subscriber preferences, please enter your contact information below. Data submitted to the former PSO after midnight on March 31 would not be protected. PDF Strategies to Improve Patient Safety: Draft Report to Congress for By establishing strong protections, providers may engage in more detailed discussions about the causes of adverse events without the fear of liability from information and analyses generated from those discussions. AHRQ has received many questions regarding the implementation of the Patient Safety Rule and about PSOs. The Notice extending the public comment period was published in the Federal Register on March 18, 2021. If a PSO's listing is revoked for cause, healthcare providers may continue to submit data to the delisted PSO for 30 calendar days, beginning on the date and time that the PSO is delisted and ending 30 days thereafter. The Common Formats are also available in the public domain to encourage their widespread adoption. Senior Administrative Assistant - TFT - Quality and Patient Relations Content last reviewed July 2021. Submitted Under Contract HHSA2902014000091 by . We've encountered a problem, please try again. No, the Patient Safety Rule requires that a PSO's appropriately qualified workforce includes "licensed or certified medical professionals." Generally, what are the staffing and personnel requirements of a PSO? ISO 9001 offers an orderly, disciplined approach to managing a healthcare organization. Learn about the priorities that drive us and how we are helping propel health care forward. If the same PSO specializing in pediatric safety events maintains a geriatrician as the only workforce medical professional, the PSO would have an insufficiently qualified workforce. Ikechukwu Enyeribe Anyanwu is a resourceful Physician, Public Health Specialist and Change Agent, with over eight years of experience in Clinical Management, Research, Strategic and Cross-functional Leadership. PSQIA establishes a voluntary reporting system to enhance the data available to assess and resolve patient safety and health care . The health system must first identify and describe (measure) a safety issue, act to help the patient (intervene), and then avoid similar events in the future (prevent). Take advantage of our award-winning Speak Up program, which has carried our patient safety message to more than 40 countries. This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatric safety initiatives, care transitions, reporting systems and antimicrobial stewardship programs. MS Quality Improvement Coordinator Eurojobs.com: MS Quality Improvement Coordinator, South Tyneside We use cookies to make your experience of using our website better. What are the circumstances in which a component PSO may not engage an individual or unit of its parent organization in the work of the PSO? AHRQ has published a short brochure, "Choosing a Patient Safety Organization," to help providers select a PSO appropriate to their needs. AHRQ is responsible for the provisions dealing with the listing of PSOs such as administering the certification processes for listing; verifying that PSOs meet their obligations under the Patient Safety Rule; working with PSOs to correct any deficiencies in their operations; and, if necessary, revoking the listing of a PSO that remains out of compliance with the requirements. The Patient Safety Rule requires that a component PSO maintain PSWP separately and securely from the rest of the parent organization of which it is a part. ThePSO readmissions Web pagecontains helpful information and tools that can be used by such hospitals, and PSOs that work with those hospitals, to address the causes of unnecessary readmissions. The Joint Commission web site no longer maintains a look-alike/sound-alike medication list; please refer to the ISMP web site referenced above for a current list of look-alike/sound-alike medications. To sign up for updates or to access your subscriber preferences, please enter your email address below. The legislation provides confidentiality and privilege protections for patient safety information when health care providers work with new expert entities known as Patient Safety Organizations (PSOs). Karen Chaves . To implement the Patient Safety Act, the Department of Health and Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ) published the Patient Safety and Quality Improvement Final Rule (Patient Safety Rule). The voluntary dimension of PSQIA is key. Alliance big ideas, committed collaborative network of learners expanding and progressing each year. AHRQ Quality and Safety Review System (QSRS). In addition, hospitals can compare their data to others and analyze trends on a community, regional, and national level. On July 29, 2005, the President signed the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act, 42 U.S.C. Patient Safety and Quality Improvement Act of 2005, Patient Safety Organization (PSO) Program, Resources About the Patient Safety and Quality Improvement Act of 2005, Resources for Improving Patient Safety and Healthcare Quality, Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005, Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine, Notice of Opportunity to Comment published in the Federal Register on December 16, 2020, Public Comment Period Extended for Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine, Peer Review of a Report on Strategies to Improve Patient Safety, Patient Safety and Quality Improvement Act of 2005 (Public Law 10941JULY 29, 2005), U.S. Department of Health & Human Services. COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control. By whitelisting SlideShare on your ad-blocker, you are supporting our community of content creators. Rubricfordeliverable7.docx - Rubric Below: A - 4 - Mastery In fact, any hospital can work with a PSO on any patient safety issue of the hospital's choice. This information is the basis for our National Patient Safety Goals , which we tailor for each specific program. This protection helps encourage institutions and individuals to more freely report incidents, concerns, and near misses. An entity does not need to be listed as a PSO or working with one to use the Common Formats. AHRQ, on behalf of the Secretary of the U.S. Department of Health & Human Services, lists entities as PSOs when they meet the applicable requirements in the Patient Safety Act. Health care professionals whose focus is on occupational health and safety, however, are likely aware of additional statistics that are less well known: health care workers experience some of the highest rates of nonfatal occupational illness and injuryexceeding even construction and manufacturing industries. If a PSO only engages in the collection and analysis of patient safety work product involving non-institutional pediatric safety events, the PSO's requirement to have an appropriately qualified workforce would be satisfied by a currently licensed pediatrician who is a member of the PSO's workforce and has sufficient knowledge, expertise, and experience related to non-institutional pediatric safety events. PSWP may only be disclosed pursuant to an applicable disclosure exception (seePatient Safety Rule Section 3.206). An official website of Providers that work with a PSO can benefit from the ability of PSOs to aggregate data from all of the providers reporting to the PSO, enabling many PSOs to develop the large numbers of patient safety events essential for identifying the underlying causes of infrequent, but often tragic, adverse events. What is AHRQ's role in providing technical assistance? The CFS is used in the AHRQ Quality and Safety Review System (QSRS). Learn more about PSQIA and read the statute. What is the purpose of the Patient Safety and Quality Improvement Act of 2005 (PSQIA), Public Law 109-41? Learn more about the Patient Safety Rule and read the regulations. > For Professionals All PSWP submitted to a former PSO in accordance with provisions of the Patient Safety Act and Patient Safety Rule remains protected after the PSO ceases operations. Frequently asked questions and definition of terms used in the Patient Safety Act or Patient Safety Rule are summarized here solely for convenience; always rely on the actual text of the Patient Safety Act or Patient Safety Rule in making any determination. Learn about the "gold standard" in quality. PSOs create a secure environment where clinicians and healthcare organizations can collect, aggregate, and analyze data, thus identifying and reducing the risks and hazards associated with patient care and improving quality. Search All AHRQ U.S. Department of Health & Human Services, Efforts to improve patient safety and the quality of healthcare delivery, The collection and analysis of patient safety work product (PSWP), The development and dissemination of information regarding patient safety, such as recommendations, protocols, or information regarding best practices, The utilization of PSWP for the purposes of encouraging a culture of safety as well as providing feedback and assistance to effectively minimize patient risk, The maintenance of procedures to preserve confidentiality with respect to PSWP, The provision of appropriate security measures with respect to PSWP, Activities related to the operation of a patient safety evaluation system and to the provision of feedback to participants in a patient safety evaluation system. The bill, signed into law July 29, 2005, provides legal protection of information voluntarily reported to patient safety organizations (PSOs). Click here to review the details. L. 114-74). See how our expertise and rigorous standards can help organizations like yours. The diagram shows the flow of protected information, to be handled as PSWP. Using ISO 9001 in Healthcare: Applications for Quality Systems Nonidentification requires that the information identifying individual and institutional providers, patients, and provider employees reporting patient safety events be removed from the PSWP. AHRQ then finalizes the Common Formats draft and releases it through the PSOPPC. The Patient Safety and Quality Improvement Act of 2005 (PSQIA) establishes a voluntary reporting system designed to enhance the data available to assess and resolve patient safety and health care quality issues. What are the Common Formats for Event ReportingDiagnostic Safety (CFER-DS)? PSWP can undergo nonidentification for combination with data from other PSOs, to become publicly accessible. Patient Safety and Quality Improvement Act of 2005 Statute & Rule If the component PSO's parent is an excluded entity that is permitted to form a component PSO, the PSO may utilize only individuals or units of its parent organization that are not involved in the ineligible activities (see 3.102(c)(4)(ii)(B)). 116th Congress (2020). There are two provisions in the Patient Safety Rule that address requirements for a PSO to maintain personnel for PSO operations. Dr. William B. Munier discussed the development and implementation of PSOs in an AHRQ WebM&M interview. Southern Baptist Hospital of Florida v. Charles. The current versions of all of the Common Formats can be found at the PSO Privacy Protection Center (PSOPPC) website. Policies, HHS Digital Department of Health & Human Services. First, a PSO must have appropriately qualified workforce members, including licensed or certified medical professionals, as described in the PSO listing criteria at 42 CFR 3.102(b)(2)(i)(B). It is intended to facilitate the collection and organization of a basic set of meaningful data about diagnostic safety events that can be used, aggregated, and analyzed for learning and improvement. CFER-DS Version 1.0 will be released with a complete set of technical specifications available through the PSO Privacy Protection Center (PSOPPC) website. How does an entity apply to become a PSO? PSQIA authorizes HHS to impose civil money penalties for violations of patient safety confidentiality. The Patient Safety Act amended Title IX of the Public Health Service Act to provide for the improvement of patient safety and to reduce the incidence of events that adversely affect patient safety by authorizing the creation of patient safety organizations (PSOs). If the only workforce member with medical knowledge, expertise, and experience is the pediatrician and the pediatrician has insufficient medical knowledge, expertise, and experience regarding nursing homes, the PSO would not have a qualified workforce that is appropriate to collect and analyze patient safety work product involving nursing homes. A contractor that is not under the direct control of the PSO is not a workforce member for purposes of the appropriately qualified workforce requirement. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. The uniform Federal protections that apply to a provider's relationship with a PSO are expected to remove significant barriers that can deter the participation of healthcare providers in patient safety and quality improvement initiatives, such as fear of legal liability or professional sanctions. Patient Safety Tools | Agency for Healthcare Research and Quality Learn about the development and implementation of standardized performance measures. Depending upon the specific activities and services to be performed by the PSO, medical doctors and/or other licensed or certified medical professionals with sufficient expertise to be able to perform the PSO's patient safety activities may satisfy the PSO's requirement to have appropriately qualified workforce members. Learn more about effective communicationScreen Reader Text. By not making a selection you will be agreeing to the use of our cookies. The original Notice of Opportunity to Comment appeared in the Federal Register on December 16, 2020. PSOs serve as independent, external experts who can assist providers in analyzing data that a provider voluntarily chooses to report to the PSO. DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers. L. 109-41, 42 U.S.C. What role will OCR have regarding the Patient Safety Rule? A component PSO must require that members of its workforce and any other contractor staff not make unauthorized disclosures of patient safety work product to the parent organization(s). Slowly and steadily we're working with you to improve patient safety, marching toward the day when health care is viewed as a high-reliability industry. To encourage the reporting and analysis of medical errors, PSQIA provides Federal privilege and confidentiality protections for patient safety information, called patient safety work product. Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. If so, is the PSWP protected? Also, a PSO is a business associate of a HIPAA-covered provider subject to the business associate requirements of the HIPAA Privacy Rule. QUALITY IMPROVEMENT AND PATIENT SAFETY - [PPT Powerpoint] - VDOCUMENTS L. 101-140), as amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (section 701 of Pub. 42 USC CHAPTER 6A, SUBCHAPTER VII, Part C: Patient Safety Improvement PATIENT SAFETY AND QUALITY IMPROVEMENT ACT OF 2005 VerDate 14-DEC-2004 11:17 Aug 05, 2005 Jkt 039139 PO 00041 Frm 00001 Fmt 6579 Sfmt 6579 E:\PUBLAW\PUBL041.109 APPS10 PsN: PUBL041 . The Patient Safety Act makes PSWP privileged and confidential. To encourage the reporting and analysis of medical errors, PSQIA provides Federal privilege and confidentiality protections for patient safety information, called patient safety work product. PDF Department of Health and Human Services - Agency for Healthcare OCR enforces these confidentiality protections. A PSO's workforce includes any individual whose conduct is under the direct control of the PSO. Introducing the Next-Gen Patient Safety Organization, World Patient Safety Day 17 September 2020, Simple and Safe Approaches Towards Patient Safety, PPT ON QUALITY IMPROVEMENT& PATIENT SAFETY. Before working with a PSO, however, healthcare providers are encouraged to review AHRQ'sdirectoryto confirm that the entity being considered is still a listed PSO. However, the Federal privilege and confidentiality protections only apply to information developed as patient safety work product by providers and PSOs working under the Patient Safety Act. Data submitted during this 30 day period are treated as PSWP and are subject to the confidentiality and privilege protections of thePatient Safety Act. A health insurance issuer may not form a component PSO, but the other excluded entities listed in 3.102(a)(2)(ii) may do so. What is an example of how a PSO's collection and analysis of patient safety work product could change requiring additional expertise? To sign up for updates or to access your subscriber preferences, please enter your email address below. Is every PSO required to engage a medical doctor to meet the appropriately qualified workforce requirement? PSOs were created by the Patient Safety and Quality Improvement Act of 2005 (the Patient Safety Act). Patient Safety and Quality Improvement Act of 2005 | PSO Drug Shortages: FDA's Ability to Respond Should Be Strengthened. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Chapter 89: PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY EVALUATION These meetings are announced on the same PSOPPC website and are open to the public. AHRQ's Common Formats are a set of standardized definitions and formats that make it possible to collect, aggregate, and analyze uniformly structured information about patient safety for local, regional, and national learning. Improving Diagnosis in Medicine Act of 2022. Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. Activate your 30 day free trialto continue reading. The CFERDS is designed to help healthcare providers identify and report missed opportunities in the diagnostic process in a standardized manner across healthcare settings and specialties for the purpose of learning about how to improve diagnostic safety and better support clinicians in the diagnostic process. Kuldeep Yagik - Senior Manager - Global Quality Project Manager 03/15/12 NNLM Advocate {NPSF} going with patient to doctor/ hospital, being willing to speak up. Which agencies within the Department of Health and Human Services (HHS) implement the Patient Safety Act? A proactive patient safety methodology includes four central aspects: Are there additional requirements for a component organization? Is a PSO required to engage with additional experts if the PSO adjusts its activities or areas of focus? A - 4 - Mastery Clear and thorough summary of the common threats to quality improvement Provided . 1 QUALITY IMPROVEMENT AND PATIENT SAFETY 2 WHAT IS QUALITY ?