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Simple solutions for patient safety
The HealthLeaders Media Industry Survey 2009, released earlier this week, shows that many healthcare leaders think that while technology is an important part of patient care, driving home the fundamentals of patient safety is actually more important. For example the notion that handwashing is far more effective at preventing HAIs than implementing some sort of technology that monitors infection rates. In fact, only 12% of who answered the survey said that their electronic medical records played a large part in improving quality and patient safety.
The cause analysis: What’s your diagnosis?
As part of the Peminic-Greeley PSO’s services, organizations recieve a comprehensive cause analysis to determine the underlying reasons why errors occur (or don’t occur). We really focus on offering a personal solution based on your specific details. Below is a snippet from an interview I had with Heather Comak, managing editor of Briefings on Patient Safety, a publication of HCPro, Inc. In this part of the interview, we were discussing what makes the Peminic-Greeley PSO different from others.
Trying to decide if joining a PSO is right for you?
If you’re part of an organization that is not sure if joining a Patient Safety Organization is right at this time, here are some suggestions on what you can focus on to gain internal buy in:
- cost of learning savings
- benefits of identification of approaches to eliminate “No-Pay Events”
- benefits of aggregation services
- benefit of protections (if applicable)
This first bullet point, about the cost of learning savings associated with a PSO will be a big reason why hospitals decide to join. Shared knowledge is a powerful tool and in an industry like healthcare it can not only save lots of money, but save the lives of patients.
A word about Common Formats
The AHRQ has developed a list of “Common Format” in which it needs any data coming from a PSO. What this means is that hospitals have many different ways of reporting events and data and for the AHRQ to make sense of any data gleaned by a PSO, that data must all look the same. To help facilitate this, created this list of Common Formats to ensure that the technical reporting specifications for data collected by hospitals and PSOs are in the same vein.
This is a vital part of making sure any data collected and aggregated by PSOs is not only put to good use by helping individual facilities survey where their problem spots are, but also for the greater good of hospitals and keeping patients safe.
However, we urge you not to become too bogged down with common formats.- Let your PSO map your existing data structure into the Common Formats to prevent disruption of your internal processes. -There is a high burden to making large changes in your exception reporting taxonomy just to participate in a PSO.
In celebration of the final rule
The AHRQ’s final rule about Patient Safety Organizations (PSO) became final today, capping off a nearly four year process. Let’s take a look at the PSO timeline:
The next four years are sure to be exciting in the world of PSOs. We now have the opportunity to really utilize the intent of the final rule, which is ultimately preventing medical errors and keeping patients safe.
The importance of a good Patient Safety Evaluation System
If you’ve been reading up on the AHRQ’s language surrounding Patient Safety Organizations, you might have seen the term Patient Safety Evaluation System (PSES) thrown around. This is a fancy way of saying the internal process that a hospital sets up to manage the collection of information that will be reported to the Patient Safety Organization. Any information that is stored in the PSES can become Patient Safety Work Product (PSWP). A good PSES will make a difference in how your organization interacts with your PSO. In fact, a well-defined PSES is essential to the successful use of a PSO by your organization.
If a PSES is designed effectively, it will take into consideration the following:
- disclosure
- peer review
- credentialing
- risk/ protection
- quality and performance improvement
- human resources
Question from the Field: “Our Lawyers are encouraging us to declare all our occurrence reports as Patient Safety Work Products (PSWP)” – Is this the right thing to do?
This question gets right to the heart of one of the stickiest issues related to the effective use of a PSO –How do we balance protection with usability of your occurrence reports? The protection aspects of the PSO are designed to encourage each facility to have a free and open reporting culture that allows for asking the tough questions in a protected environment. That’s good because if we don’t ask the tough questions we won’t get to the right solutions. So we probably want to protect our deeper analysis as PSWP (Patient Safety Work Product).
The flip side is that when we protect the data as PSWP we also limit the ability to use that data in some of our normal existing processes and that can have a real negative impact. For example, if you declare an occurrence report as a PSWP you need to carefully look at the impact that has on your ability to disclose that event, or use it in credentialing or as a normal part of staff management. So like everything it is really a matter of balance.
When a new member joins the Peminic-Greeley PSO one of our first steps is to have our consultants work with the member to make sure that they have defined their PSWP and PSES appropriately and that they have integrated it with the other existing processes. This is where our Peer Review, Credentialing, Accreditation and Disclosure experts can be of assistance.
Our goal is to make sure that the Peminic-Greeley PSO is useful to your organization so it is important to us that it is not just another data stream but that it fits smoothly with all your other hospital processes so you can effectively tap this vital new resource.
How do we keep from getting overwhelmed with all the data?
Every day we all need to weed through a tremendous amount of data looking for those small nuggets that will help us see clearly hat we have to do to make our facilities safer and more efficient. One of our foundations at the Greeley Company when we talk about data analysis is to always remember the four simple questions. You will see that same philosophy throughout the Peminic-Greeley PSO analysis and reporting.
So what are the “Four Simple Questions?” They are nothing new; you probably use them when you are looking at your personal checkbook. But from our PSO perspective looking at our process performance data, we can phrase them as below.
- “So is it too much or too little?” (MAGNITUDE)
- “So is it getting better or worse?” (DIRECTION)
- “So is it under control or out of control?” (VARIABILITY)
- “So is it moving so fast I have to take immediate action or do I have time to think?” (RATE of CHANGE)
Answering these four simple questions is a great way to make sure your data is useful to you and your organization. You will see lots more on this as we begin to analyze the incoming PSO data.
If you are interested in more details you can go to the White Paper located in the PSO Member’s Library.
Happy New Year from the Peminic-Greeley PSO Team!
It is exciting to start 2009 with the ability to work with all our clients and PSO Members. We are all looking forward to a busy time as the PSO momentum builds over the next year. The economy will continue to put a tremendous amount of pressure on all of our facilities and that is sure to bring some difficult challenges including budget and staffing issues in the quality, safety and performance improvement areas. We recognize that our PSO members are living in this new environment and need to be able to do much more with less. We are confident that the benefits of aggregation of our learning can help all of us be safer, more efficient and yes, even more competitive. We are committed to assisting our members reach your goals in 2009 and be successful. As always, we will judge our success in 2009 on how well we manage to support you, our Members in getting to realistic, effective solutions more rapidly through the support from the PSO.
Our best wishes to all of you and yours for a great 2009!
How does the Peminic-Greeley PSO Work?
From a very simple standpoint, a PSO provides two key benefits to its members. These include Aggregation of Data and Protection of Analysis. The Peminic-Greeley PSO is structured such that the members can submit data for both of these purposes.
You can submit Occurrence Report data, Cause Analysis Data and Peer Review data to the PSO where it is de-identified and aggregated with data from other members and then analyzed and key points reported back to you based on the level of your membership.
In addition if you declare that data or analysis is a Patient Safety Work Product (PSWP) based on the rules in your Patient Safety Evaluation System (PSES) then it will be registered as such and be protected as such. We will talk about PSWP and PSES in other columns because there are some important details there. We work with our members to assist you in setting up an effective definition and management system for PSWP and your PSES.
The PSO Consultants constantly review the PSO data and provide feedback to the members through the PSO website, the regularly schedule member webinars and special notifications. In addition your membership provides access to the solutions library where the PSO consultants post what we consider best practice solutions and recommendations as well as feedback from the field and the members on what has worked for them.