Patient Safety Organization

Want to Know More About the History of PSOs?

In July 2005, Congress developed the federal Patient Safety and Quality Improvement Act of 2005 in response to the IOM (now known as National Academy of Medicine) report, To Err Is Human.

The final Patient Safety Rule was adopted November 21, 2008 and became effective on January 19, 2009. The Agency for Healthcare Research and Quality, one of the eleven divisions under the Department of Health and Human Services, oversees the Patient Safety Rule.

The Patient Safety Act and the Patient Safety Rule provide a structure for PSOs while the legislation affords protection for physicians and healthcare providers that voluntarily and confidential reporting of adverse event information to designated PSOs. The program intentionally differentiates PSO work from most regulatory and mandatory reporting programs.

In 2008, the Center for Patient Safety was the 5th federally-designated PSO in the country. The goal of the Center for Patient Safety PSO is to learn how and why events are occurring, and inform providers and others about how to prevent future occurrences.

The Patient Safety Act and the Patient Safety Rule reinforce a safety culture that encourages and allows healthcare providers to safely report and share information about vulnerabilities within the healthcare system. The Act extends confidentiality and privilege protections to:

Eligible information developed by providers for reporting to a PSO (but not to information developed for other purposes)
Deliberations and analyses conducted by either a PSO or a provider in its respective patient safety evaluation system (PSES)
Information developed by a PSO for the conduct of patient safety activities

What are the Key Functions of a PSO?

1. Confidential Data Collection

Receive reports on adverse events, near misses, unsafe conditions.
Ensure confidentiality and protection under the Patient Safety and Quality Improvement Act of 2005 (PSQIA).

2. Data Analysis

Use aggregated data to identify trends, root causes, and systemic safety issues.
Highlight high-risk areas and provide actionable insights.
Deliver tailored safety solutions and best practices.

3. Facilitate Collaboration

Encourage information sharing among member organizations to promote collective learning.
Share strategies for mitigating risks and improving outcomes.

4. Education and Training

Offer resources and programs to educate providers on safety practices.
Offer insight to develop training based on real-world data and identified needs.

From the Agency for Healthcare Research and Quality

What are the Reasons to Participate with a PSO?

When a provider works with a PSO, many of the long-recognized impediments to successful improvement projects can be overcome:

Provider fear of increased liability from participating in quality initiatives. The law provides confidentiality protections and privilege protections (inability to introduce the protected information in a legal proceeding), when certain requirements are met.
All licensed or certified health care facilities and clinicians can participate. Unlike state protections that often target hospitals or physicians, these protections are broad.
Protections are nationwide and uniform. This is especially valuable for systems with facilities in multiple states; a corporate system can share its protected data system-wide with all of its affiliated providers, if it chooses to do so.
Insufficient volume. Patient safety events are often too rare for a facility to identify causal factors with certainty. Each provider benefits from the insights that it can obtain from a PSO that aggregates large volumes of event data from multiple providers. Moreover, your data remains protected even when the PSO is aggregating it with data from other providers.
Lack of feedback. The quantity and types of data you report to a PSO and the specific types of analysis and feedback you want are a matter for negotiation with the PSO. They are not determined by regulation.
Inability to protect deliberations or analyses at your organization. The law permits providers to undertake deliberations and analyses at their facilities that become protected as Patient Safety Work Product immediately as long as they are conducted in the provider’s Patient Safety Evaluation System.

Why CPS is a PSO Leader

The Center for Patient Safety is:

A registered PSO. CPS was one of the first PSOs registered in 2009.
A non-profit organization
Dedicated to patient safety. CPS has been working to improve patient safety since its doors opened in 2005.
Supports diverse participation. CPS is one of the most diverse PSOs in the country, allowing the healthcare industry to improve together.
Mission-driven to reduce preventable harm. All CPS work is designed to support patient safety improvement efforts.
High quality and affordable. CPS offers high quality and affordable services to encourage participation.
Focused on minimizing your time commitment so you can benefit sooner. Our team of experts walks you through every step, supporting your unique needs.
Staffed by a team of experts with hands-on experience and deep knowledge to help you effectively participate in a PSO.

We offer a flexible model that works for individual providers, small to large organizations, as well as local, regional and national associations. No matter the size, we have a program that will fit your needs.

Benefits of Joining the CPS PSO

As a healthcare professional or organization, participants in the CPS PSO have access to multiple resources:

Federal legal and confidentiality protections for designated quality and safety improvement - more expansive than attorney-client privilege or peer review protections
Educational opportunities to maximize the benefit of working with a PSO, including watches/alerts
Expert support for PSO policy updates
Periodic training and handoff support
PSO Updates and Participant Meetings
Legal Updates
Submission to National Database
Participant access to PSO Toolkit with Peer-to-peer networking and sharing opportunities, Resources, On-demand training, RCA Template, and more
Integration of PSO and patient safety activities with a network of providers across the continuum of care, including EMS, hospitals, ASCs, medical offices, LTC, home care and hospice, pharmacies, and more.

Who Can Join the CPS PSO?

The CPS PSO works with:

health systems
hospitals
long term care
home care and hospice
emergency medical services (air and ground)
medical offices, physicians and physician groups
telehealth
prison medicine
ambulatory surgery centers
other Patient Safety Organizations (PSOs)
local, state and national organizations
and many uniquely structured healthcare provider groups

Not on the list above? Contact us to explore your PSO participation options.

What is the Cost to Join the CPS PSO?

CPS is a not-for-profit organization, dedicated to improving patient safety. Our annual charge is minimal and varies by provider. For hospitals, the cost is based on staffed beds. For other, smaller provider groups, a flat rate is available.

You may be a part of an organization or association that covers your participation fees with the Center for Patient Safety. Contact us to find out if you are eligible for participation at no cost to you.

We know every organization is different and has different challenges, so we'll review your unique situation and explore how PSO participation can fit your needs. Let us know a little about your organization by completing this form.

We may need to schedule a time to chat and make sure there is a fit between your organization and ours. If the fit is right, we’ll prepare a proposal and walk you through the contract and implementation process. You may find the solution is well within reach!

Working with CPS has been so easy and rewarding. The availability of their staff for questions and consultations is always just a phone call away. We are certainly a safer place for patient care by working with them.

Julie Jones Community Hospital-Fairfax

The Center for Patient Safety has become a partner on our patient safety journey. Our PSO data submission was transformed from difficult and aggravating to easy in that we now simply complete a spreadsheet with certain required fields and submit it to the Center. Couldn’t ask for anything easier!

Holly Bush Nevada Regional Medical Center

Our work with the CPS PSO has far exceeded our expectations. The CPS PSO provided much-needed assistance in creating our work processes.

Vereline Johnson Saint Francis Healthcare System