EMS PSO Educational
Webinars Session 1:
Understanding the Patient Safety
Evaluation System
January 11, 2012
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MO-09-06-MOCPS
Agenda
• An Overview - The Patient Safety and Quality
Improvement Act of 2005
• Current Reporting Processes
• PSO 101 & Acronym Soup
• How will this work in my ambulance service?
• Next Steps - Homework
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Goals of MOCPS
• To expand learning from patient safety
initiatives through collaboration.
• To serve as a federally recognized Patient
Safety Organization to collect, learn, and
share learning about adverse events in
an effort to reduce preventable harm.
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Patient Safety & Quality
Improvement Act of 2005 (PSQIA)
• Intent
– A safe environment supporting voluntary reporting, sharing,
and learning about medical errors
– Proactive prevention of medical errors
• Main provisions
– Establishing a national network of PSOs
– Providing federal-based legal protections
– Definitions for processes and procedures to participate with a
PSO and obtain the available protections
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Key Provisions of the PSQIA
• What is a PSO?
– An organization that collects data from participants
(you), studies it and develops recommendations for
safer care.
– The Missouri Center for Patient Safety is a federallylisted PSO.
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MOCPS as a PSO
• Certified with the US Department of Health and Human
Services effective November 5, 2008
• Quantros™ contracted as data partner for automated PSO
data collection, analysis and reporting
• Currently have over 180 contracts with hospitals, ambulatory
surgery centers (ASCs), and ambulance services
• Began receiving live data in 2010 from hospitals and ASCs
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Current QI, Personnel, & Legal
Processes Within Your Service
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QUALITY IMPROVEMENT
ACTIONS YOU ARE TAKING NOW
DOCUMENTS YOU ARE
COLLECTING
Supervisor notes of
trip reviews
• Focused trip reviews - all
intubations; all codes/full
arrests; all IV insertions
• Investigation of incident
reports
• Case reviews with the
Medical Director (could be
scheduled or a special request
form he supervisor/manager
• Quality committee meetings
Medical Director case
review notes/
recommendations
Meeting minutes
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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LEGAL ACTIVITIES
ACTIONS YOU ARE TAKING NOW
• Getting your attorney
involved when bad things
happen
• Reviewing trip records
• Interviews with staff and
those involved
• Informing liability insurer
when necessary
• All other activities
associated with defense of
the case
DOCUMENTS YOU ARE COLLECTING
Documentation of
discussions/emails with your
attorney
Notes from review of
trip records
Notes from interviews with
staff and those involved
Notes of discussions with
your liability insurer
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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PERSONNEL ACTIVITIES
ACTIONS YOU ARE TAKING NOW
• Annual performance
reviews
• Scheduled skills checks
• Counseling/Coaching
• Disciplinary action
• In some cases,
discussing
termination with your
Board
DOCUMENTS YOU ARE COLLECTING
Written performance
evaluations
Documentation of
attendance at inservices,
skills checks
Documentation of
remediary training when
needed
Notes of discussions with
the employee and course of
action
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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•Getting your attorney involved
when bad things happen
•Reviewing trip records
•Interviews with staff and those
involved
•Informing liability insurer when
necessary
•All other activities associated
with defense of the case
•Focused trip reviews - all
intubations; all codes/full arrests;
•Counseling/Coaching
all IV insertions
•Disciplinary action
•In some cases, discussing
termination with your Board
•Annual Performance Reviews
•Scheduled skills checks
•Investigation of incident reports
•Case reviews with the Medical
Director (could be scheduled or a
special request from the
supervisor/manager)
•Quality committee meetings
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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Working with a PSO…
… you will learn how to more clearly define
these 3 activities, and how to maximize the
confidentiality protections available to your
service.
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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The 101 on Working with a PSO
• Understanding terminology
• Applying abstract concepts
• Redefining your current
processes
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PSO Speak = Acronym Soup
Hungry anyone?
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Terminology Basics
• PSO – Patient Safety Organization - entity that is
federally listed as a PSO by the Secretary of the US
Department of Health and Human Services (HHS)
• MOCPS – Missouri Center for Patient Safety
• MOCPS PSO – Missouri Center for Patient Safety
Patient Safety Organization
• PSQIA – Patient Safety and Quality Improvement Act.
Federal legislation signed in to law in 2005 which
established the basis for the development of a
network of PSOs.
• Event or Adverse Event – An unintended or
unfavorable incident when a patient is impacted as a
result of medical treatments, procedures, or other
care, regardless of whether or not it caused the
patient permanent harm.
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Term you will be hearing FREQUENTLY:
• PSES – Patient Safety Evaluation
System.
-The collection, management, or analysis of
information for reporting to or by a PSO
-It is the mechanism by which information can
be collected, maintained, analyzed and
communicated
-It exists whenever the provider engages in
patient safety activities for the purpose of
reporting to a PSO
What in the world does this mean?
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A slightly easier definition:
• Patient Safety Evaluation System (PSES): The
components and activities that take place
within your ambulance service to improve
quality, and/or to identify, investigate, respond
to and report events and other information to
the PSO.
*Most important: The work of your PSES has to be
done with the intent that the information you
gather and create will be reported to the PSO.
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ANOTHER term you will be hearing
FREQUENTLY:
• PSWP – Patient Safety Work Product.
Any data, reports, records, memoranda
analyses, or written or oral statements
which:
– Are assembled or developed by a provider for
reporting to a PSO and are reported to a PSO, or
– Are developed by a PSO for the conduct of
patient safety activities, or
– Which identify or constitute the deliberations or
analysis of, or identify the fact of reporting
pursuant to, a PSES
And what the heck is this?
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Slightly easier….
• Patient Safety Work Product is the information
that you gather to report to the PSO and the
supporting work
• It can include: data, reports, records (but see
next slide), memos, analyses, written or oral
statements
*Most important: PSWP has to be information that is
reported to the PSO or supports the creation of
information that is reported to the PSO
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What is NOT PSWP (Patient Safety
Work Product)
• Patient’s medical record (your trip reports)
• Billing information (anything you send to get
paid)
• Any other original patient or provider record
• Information collected, maintained or developed
separately, or that exists separately from a PSES,
for example HR files, purchasing records
• Material that reflects actual changes made as a
result of the patient safety work
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Sounds Complicated. Why Report?
• Improved patient safety understanding from
aggregation of data, benchmarking
• Protection of your patient safety work from
disclosure:
– Civil, criminal or administrative subpoenas
– Discovery
– Freedom of Information Act disclosure
– Use as evidence at trial or other proceeding
– Use in disciplinary proceedings
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Ok, I get that, but…
…how is this going to work in my ambulance
service???
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Tying the basics back to EMS…
Think of your current processes as we apply these
abstract ideas to something concrete.
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QUALITY IMPROVEMENT
ACTIONS YOU ARE TAKING NOW
DOCUMENTS YOU ARE
COLLECTING
Supervisor notes of
trip reviews
• Focused trip reviews - all
intubations; all codes/full
arrests; all IV insertions
• Investigation of incident
reports
• Case reviews with the
Medical Director (could be
scheduled or a special request
form he supervisor/manager
• Quality committee meetings
Medical Director case
review notes/
recommendations
Meeting minutes
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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A Sample Current Investigation
Process
Crew reports
event to
Supervisor
Incident report is
filled out
Supervisor completes
investigation:
• Interviews the crew
•Reviews trip report
•Fields calls from the
pt/family involved
•Med Director may
review
Current
Protections:
- Attorney-client
privilege (if you
have involved
them, and only
applies to limited
things)
Many documents are
generated:
•Interview notes
•Analysis of trip report,
paramedic decision making
•Notes from phone calls
with the pt/family
•Med Director notes
Written staff action
only in extreme cases,
goes in personnel file.
Other documentation
goes in your QI files
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Other current processes
• Policies for frequency of QI committee meetings
• Procedures for routine and focused trip reviews
• Policies for Med Director case review
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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Translation to “PSO Speak…”
• All of these processes can be established within a Patient
Safety Evaluation System (PSES):
• The “easy” definition: The components and activities that
take place within your ambulance service to improve
quality, and/or to identify, investigate, respond to and
report events and other information to the PSO.
• Some details of the PSES may differ depending on the process
taking place (i.e. event investigation vs. QI meetings)
• Visual: A Blow Pop…..
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Patient Safety Evaluation
System….
Already-Existing Quality
Improvement Activities (hard candy
shell)
Mmmm,
bubble
gum!
 Examples: incident reporting processes,
supervisor investigation, med director
review, trip reviews, internal QI data
collection
 Do not receive the confidentiality
protections offered in working with a PSO
 Other protections may apply, such as
attorney/client privilege
Patient Safety Evaluation System (gooey
bubble gum):
 Any information created in the PSES
is considered Patient Safety Work
Product (PSWP)
 PSWP is eligible for confidentiality
protections through working with a
PSO.
These materials may not be distributed, published, or reproduced, in whole
or in part, without prior approval of the Missouri Center for Patient Safety.
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PSES Key Concepts
1. The work and information that takes place and
resides inside your PSES is protected from
discovery, even before you actually submit it to
the PSO.
2. You cannot use that same information residing
inside your PSES for any other purposes:
a) Cannot use it for disciplinary action
b) Cannot use it for legal defense
c) Cannot disclose to Bureau of EMS/DHSS
BUT……..
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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PSES Key Concepts
3. Anything you create OUTSIDE of your PSES can
still be used for these other needed purposes.
This means, notes and documentation you keep
for personnel purposes or for legal defense
purposes are still accessible and you can
continue those processes as before.
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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QI
Work
PSO
LEGAL
ACTIVITIES
PERSONNEL
ACTIVITES
This is where your
PSES will live; all
information inside
the purple circle is
PROTECTED and
CANNOT BE
DISCLOSED OR
USED FOR OTHER
PURPOSES.
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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Homework…
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By January 26 (the next session):
• Meet with your supervisors, QI personnel,
administrator, anyone who is currently involved in this
process – and those who will be involved in PSO work –
and map out your current process for Incident Report
investigation (see Homework Handout #1)
• Review your current policies on QI committee work; HR
disciplinary procedures; and anything associated with
reporting incidents to your attorney or liability insurer.
Answer the questions on Homework Handout #2.
These materials may not be distributed, published, or reproduced, in whole or in
part, without prior approval of the Missouri Center for Patient Safety
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PSO Implementation Steps
• If you have not returned a signed agreement to us,
WE NEED THEM ASAP!
• EMS Safety Attitudes Questionnaire needs to be
administered to all of your staff
– Some of you received an email on Nov. 15th – many of you
did not respond to our request.
– Another reminder will be sent out this week – please
respond and let us know how you would like to proceed.
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TIMELINE through April, 2012:
1. Jan./Feb. :
• EMS Safety Attitudes Questionaire needs to be
administered to all of your employees.
• Educational Webinars on working with the PSO.
2. Feb./Mar.:
• Develop your service’s PSO policies (templates will be
provided on the next webinar)
3. March/April - Have draft policies reviewed by MOCPS
4. By end of April - Begin reporting to MOCPS PSO.
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Questions?
Missouri Center for Patient Safety
www.mocps.org
573-636-1014, 1-888-935-8272
Carol Hafley, MHA, BSN, RN, FACHE – chafley@mocps.org
Missouri Ambulance Association
816-215-8524
Jason White – jason.white3254@gmail.com
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