We all know it “takes a village” to ensure safe care, so the Center for Patient Safety recommends hospitals encourage family members as well as employees to be patient advocates. The Joint Commission just released its 10th “Speak Up” video – a great resource to share with patients, family members and employees.
A proposed rule implementing several provisions of the Affordable Care Act (ACA) has been issued for comment through December 26th. The proposed rule, beginning on page 171, addresses the ACA’s requirement for hospitals to meet patient safety and quality improvement requirements in order to be eligible to contract with a qualified health plan that participates in the new health insurance exchanges. As initially written, Section 1311 of the ACA included a provision requiring hospitals with more than 50 beds, by January 2015, to meet certain patient safety requirements, including using a patient safety evaluation system (PSES). The newly proposed rule clarifies that a PSES is the collection, management or analysis of information for reporting to or by a patient safety organization (PSO). However, the Centers for Medicare & Medicaid also indicate, within the proposed rule, they intend to delay the PSO participation requirement due to several challenges with the 2015 deadline. Beginning in 2015, hospitals will be required to meet current CMS requirements for patient safety and quality improvement while CMS develops further regulation for implementation of the patient safety provisions over the next two years. Comments on the proposed rule are due December 26, 2013.
- Just Culture and Learning from Errors
- Things to Ask When Considering Joining a PSO
- More Case Law Provides Support for PSO Protections
- Final Recommendations Published from the NHTSA Culture of Safety Project
- EMS Data System Gets a Boost from VergeSolutions
CONTACT A MEMBER OF THE CENTER’S PSO TEAM FOR MORE INFORMATION:
- EMS PSO participation and implementation: Carol Hafley, firstname.lastname@example.org
- Hospital & ASC PSO participation and implementation: Eunice Halverson, email@example.com
- Survey on Patient Safety Culture, PSO data system, technical support: Alex Christgen, firstname.lastname@example.org
For additional information on the Center’s PSO activities, previous newsletters, resources, toolkits, upcoming events, Survey on Patient Safety, and more, please visit the other pages on our website, or for the most up-to-date news, follow us on Twitter @PtSafetyExpert or subscribe to eNews updates.
AHRQ’s recent bulletin highlights their new toolkit directed at medical offices to make the care delivery process safer: “Improving Your Office Testing Process: Toolkit for Rapid-Cycle Patient Safety and Quality Improvement”
The toolkit includes materials for assessing office readiness, planning for improvements, assessing the testing process, patient engagement, patient handouts, and chart audit and EHR evaluation tools. To find out more from AHRQ and download the toolkit, we encourage you to visit their website.
Next free WIHI broadcast from Institute for Healthcare Improvement (IHI) is Thursday, November 7, 2013, at 1PM CT: Improving Safety and Satisfaction in Ambulatory Care.
“We don’t typically associate the ambulatory care setting with serious lapses in quality that threaten patient safety. Much of the improvement in recent years targeting outpatient care has focused on access, waiting times, communication, and coordination of care. But these areas ripe for change have often obscured others that, if not handled well, can have even more dire consequences: the ordering of tests, the timely handling and communication of results, and the overall process of making a diagnosis in response to a patient’s symptoms or complaints, including making referrals to specialists… On the program, we’re going to find out what’s been learned from a three-year initiative known as PROMISES, charged with reducing malpractice risk in the ambulatory setting by making care safer, more efficient, and more reliable.”
Speakers for this broadcast will include Gordon Schiff, MD, Associate Director, Brigham Center for Patient Safety Research and Practice, Brigham and Women’s Hospital; Nicholas Leydon, MPH, Director, PROMISES Project, Massachusetts Department of Public Health; Frank Federico, RPh, Executive Director, Strategic Partners, Institute for Healthcare Improvement (IHI); Damian Folch, MD, Family Practice and Lifestyle Medicine (Chelmsford, MA).
This recent article form the New England Journal of Medicine discusses how to talk to about other clinicians’ errors. The article discusses the challenges, the importance of patient and family focus and need for institutional involvement. http://www.nejm.org/doi/full/10.1056/NEJMsb1303119?query=TOC
1. Transparency contributes to improved patient safety for all
2. Take advantage of safe haven of federal protection for safety work product, especially in light of Missouri’s recent tort reform decision
– Protect patient safety discussions and analysis currently taking place between hospitals and providers, ie EMS re: trauma, STEMI and stroke
– Future integration with providers who are members of Accountable Care Organizations
3. ACA provision effective January 1, 2015 requires all hospitals with 50 or more beds to have a patient safety evaluation system to receive reimbursement from the HIE plans
4. Position for recent recommended requirements by the Office of the National Coordinator for Health Information Technology (ONC – HIT) to report patient safety events related to EHRs to a PSO
5. Active participation in PSO provides strong counter-argument to proposed bills requiring mandatory reporting to the state Department of Health, including increased surveys and fines
The Institute for Safe Medication Practices (ISMP) began publishing a newsletter for long-term care providers in July, outlining LTC’s special issues and solutions for medication safety. If you don’t already get the newsletter, you can find the October edition at http://www.ismp.org/newsletters/longtermcare/issues/LTC201310.pdf and find past editions or subscribe here. The October edition addresses “wrong resident” events.
The ISMP’s expertise comes from events reported by providers, and it is a great example of the value that can come from a reporting and learning culture.
Providers can report medication events to ISMP (instructions are in the newsletter). ISMP is a listed Patient Safety Organization (PSO), and so the information providers send them is protected IN ISMP’s HANDS. However, the information in the PROVIDERS’ hands may still lack protection if the provider does not have a contract with a PSO and a policy defining its Patient Safety Evaluation System. Participants who report to the Center for Patient Safety’s PSO can also share medication event information with ISMP. There is more information about the CPS long-term care PSO at www.centerforpatientsafety.org/ltc.