AHRQ Posts Medical Office Toolkit for Tests

Some of the best-known safety speedbumps for physician practices lie in the patient testing area.  Orders have to be developed and communicated, results communicated from the lab to the office and then to the patient or other providers.  The provider who ordered the test has to see the results and react appropriately.  Documentation of this process needs to be complete and accurate.   AHRQ has developed a toolkit to address this issues in collaboration with the University of Colorado.  It is available here.  [link:  https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-care/labtesting-toolkit.html?utm_source=ahrq&utm_medium=en&utm_term=&utm_content=1&utm_campaign=ahrq_iltp_2018]  And remember that in support of that work, the Center for Patient Safety offers the AHRQ Safety Culture Survey for Medical Offices, along with follow-up support to improve the culture behind the work.


QAPI: 10 Steps to Improvement

Long-term care providers face new expectations for their safety and  quality work in the form of CMS’ QAPI standards. Yet a simple and methodical approach can help LTC providers create a program that meets CMS’ expectations and improves care for residents. Primaris has published a great list of suggestions (“10 Simple and Effective QAPI Planning Tips”) for those who want to strengthen their program; it is available here.

And remember:  CPS has tools and programs that can be integrated into this planning for an even stronger program. The AHRQ Survey of Safety Culture helps LTC organizations identify areas ripe for QAPI improvement and helps measure baseline and post-intervention safety culture to demonstrate improvement.  CPS also offers programs to help with the improvements that might grow out of the survey.  And organizations that participate with CPS’ Patient Safety Organization (PSO) can share their learning and protect it from discovery at the same time.

For  information about the AHRQ Safety Culture Survey, contact Alex Christgen ([email protected]).

For  information about  the Center for Patient Safety PSO, contact KathyWire ([email protected]).

Florida Supreme Court’s opinion in Charles vs. Southern Baptist

A note to CPS’ participants and friends:

The Florida Supreme Court has adopted a restrictive interpretation of the PSQIA as it relates to Florida’s risk management and discovery laws.   Charles vs. Southern Baptist analyzes the relationship between the Patient Safety and Quality Improvement Act (the Act) and Florida laws that govern the development and protection of patient safety and quality material.  The Court’s opinion is available here.

Providers in Florida need to get local legal advice about the extent of the state law impact on their safety and quality work, as this is the first step in applying Charles.   Though the decision has no direct impact in other jurisdiction, it will be part of the ongoing discussion about PSO protections, so it is important to understand it. The key facts:

  • Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state.   The statute also requires the hospital to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities.
  • The discovery request specifically asked for reports prepared pursuant to parts of the statute.
  • The court recognized the applicability of the Patient Safety Act and accepted that the hospital had a PSES and that the information was utilized appropriately in that context, and therefore would be protected PSWP except for the state risk management and reporting requirements.
  • The court found that the need to gather the information under state law and to report some of it precluded it from being protected PSWP.


The Court held that patient safety work and the related reports, when required by state law, could not be PSWP, using the same analysis put forth by AHRQ in its Guidance last year. (AHRQ Guidance document available here.) Because the Charles information was collected or maintained for a purpose other than submission to a PSO or for dual purposes, the Court held it is excluded from the definition of PSWP contained in the PSQIA and the final rule.

This finding (that the requested information was not protected PSWP) is important when examining the next issue, whether the PSQIA pre-empts Florida Amendment 7. That provision eliminates any protection for “any records made or received in the course of business by a health care facility or provider relating to any adverse medical incident.”  This discussion won’t delve into the detailed interaction of the PSQIA definitions and Amendment 7, though the relationship is complicated.  The important thing for PSOs and their participants in other states is the Florida Court’s somewhat gratuitous finding that the PSQIA could not supersede or pre-empt Amendment 7.

CPS doesn’t recommend that its PSO participants assume that Amendment 7 has pre-empted the PSQIA. There are several reasons why PSO participants should not view this as established doctrine (or in non-legal parlance, a “done deal”):

  • The Court’s pre-emption finding may well be dicta–an opinion stated by a court that is not necessary for its decision.  Dicta can be informative, but carries little true weight as precedent.  Viewed narrowly, this is just the Florida Supreme Court stating its opinion where it doesn’t really matter.
  • The Florida finding directly contravenes language in the PSQIA (Section 922): ‘‘(a) PRIVILEGE.—Notwithstanding any other provision of Federal, State, or local law, and subject to subsection (c), patient safety work product shall be privileged.”  This sets up a potential US Supreme Court appeal.  The US Supreme Court could either (1) accept the case and decide the pre-emption question or (2) find that the Florida Court’s statement was dicta and did not raise a real issue.

Applying Charles:

CPS has always advised its participants to divide their safety and quality work into 3 categories:

  1. Reports that have to be submitted under state or other federal law,
  2. Work that is required to be done and related documents that must be generated but not reported under state or other federal law, and
  3. Work that is not required by other law.


Under Charles, documents produced to meet an independent state law requirement (Category 1) are not eligible to be PSWP. Work product that results from other state-required activities (Category 2) is in a gray zone and the answer may depend on state law and how you have structured the work.  If you have questions, contact CPS.  Review your mandatory activities and reports (bullets one and two above) and design your PSES to include work that is done outside those categories. Your PSES can always consider non-PSWP; the deliberations and analysis within the PSES can be protected, but the non-PSWP work product cannot.

There remains an open issue of admissibility in court for any of this information.  That is another fight for another day.

CPS will keep you advised of new developments.

CPS will keep you advised of new developments.


Patient Safety Awareness Week Approaches, March 12-18th

The Center for Patient Safety (CPS) encourages all healthcare organizations to use Patient Safety Awareness Week, March 12-18th, as a way to remind staff and community of your commitment to safety. It should be a time of celebration of successes, but also a time of reflection.

Free Toolkit for Patient Safety Awareness Week 2017

CPS reminds you to plan in advance for Patient Safety Awareness Week. Plans don’t have to be time consuming or extravagant, but a little planning can go a long way. We recommend hosting an event or several events to recognize patient safety efforts at your organization.

For example:

  • Recognize staff and committees that work every day to provide safe care
  • Launch a patient safety culture assessment during the week (mention this blog and receive 10% off your survey services through CPS!)
  • Have leadership, patient safety/risk/quality department and/or safety committees host events in the cafeteria with snacks or dessert or something special to celebrate safety at their organization
  • Ask departments to develop poster presentations of their successful safety efforts. Display in hallways.
  • Hang a safety awareness week poster in the foyer of the organization with signatures from all staff
  • Hold safety-focused training during Patient Safety Awareness Week
  • Publish safety-focused articles for the organization’s internal newsletter, professional newsletters, local newspapers, local consumer groups
  • Contact a local radio station to host a spokesperson to share patient safety tips and highlights
  • Launch a new safety awareness effort – a “good catch” program, implement a new “CUSP Team”, announce an upcoming “Safety Culture Survey”, etc.

Several available toolkits can support improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also suggest you consider consumer involvement to ensure a successful week. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement events and programs during Patient Safety Awareness Week:

Visit www.unitedforpatientsafety.org for more information and resources about #PSAW2017.

Just Culture Results and Patient Safety Culture Survey

CPS has long believed that Just Culture principles of accountability are a great way to address issues highlighted Safety Culture Survey results.  It focuses on system response, strong investigation and analysis of employee choices so that organizations can improve systems while dealing with their employees in a fair and just manner.

AHRQ, the agency that developed the Survey of Safety Culture, is offering a free webinar, “Using Just Culture to Improve Hospital Survey on Patient Safety Culture Results.”  Though the program primarily addresses hospitals, the principles will apply to any healthcare provider organization.  CPS encourages providers to attend this program and learn more about the survey and how Just Culture can help.

For additional information about the Center’s survey or Just Culture offerings, contact the Center for Patient Safety (888-935-8272) or check out our website, www.centerforpatientsafety.org.

Changing Patient Safety Culture

Transparency is one of the biggest challenges in changing patient safety culture.  Frank Federico, VP at IHI, shares viewpoints in his recent blog.  Remember the CANDOR toolkit (noted in his blog) is available for free from AHRQ and can be helpful in implementing culture changes around communication with patients and family members. Read IHI blog.

AHRQ Guidance: PSOs, Parent Organizations and Affiliated Providers

The Patient Safety and Quality Improvement Act (PSQIA) and its associated regulation allow affiliated providers to share protected PSWP.  Providers are “affiliated” if they either have a parent/subsidiary relationship or are common subsidiaries of a single parent.  The regulation outlines the requirements for those categories, but generally the parent must have control over the subsidiary/affiliated organization.  (We recognize that many non-profit organizations use a term other than “subsidiary,” but we will use it here to generally represent the non-parent.)

AHRQ published a new guidance document in June 2016 which discusses these issues in further detail and also outlines some situations in which potentially related organizations would not qualify as “affiliated.”  The Guidance stresses that the meaning of “parent organization” may be broader than it is in corporate law, and that it depends on “actual organizational control, rather than the organizational structure.”   AHRQ defines “control” as “the authority to control of manage agenda setting, project management, or day-to-day operations” of the subsidiary entity.  AHRQ stated that it intends to retain a great deal of flexibility in this interpretation.  Ownership of enough stock to control the subsidiary also qualifies; the ownership need not be a majority to create control.  A PDF of the new Guidance is available at:  https://pso.ahrq.gov/legislation/assessment.

The Agency is less forgiving in reviewing multi-level arrangements, where a high-level parent sits over a system, which sits over individual provider entities.  The ability to control must reach from the top to the bottom for all these organizations to be affiliated providers.

Items for consideration:

  1. PSO participants relying on the “affiliated provider” provision should review the new Guidance.
  2. Be careful to review other documents and pleadings to make sure that the participant is not making statements denying control in the context of, for example, efforts to establish parent-organization liability in a malpractice case.
  3. Multi-level organizations need to review the Guidance and make sure their PSWP workflow is in compliance. Remember, representatives of a non-affiliated parent can still be part of a facility workforce, so long as they meet the requirements.  And aggregated data can flow to the non-affiliated parent.
  4. A PSO that resides at the upper level of an organization will not be affected by this Guidance, but it will be constrained to follow all PSWP requirements that apply to PSO’s.


The statute and regulation are available at https://pso.ahrq.gov/LEGISLATION.  Participants in the Center for Patient Safety PSO may contact the Center at any time with questions.

Cultural Transformation

A study completed at The Ohio State University, and published in the American Journal of Medical Quality, shows a patient safety cultural transformation after implementation of Crew Resource Management.  AHRQ’s Survey of Patient Safety (SOPS) tool was used to measure progress of the culture improvement.  The Center for Patient Safety offers low-cost, high-value administration and department-level analysis of the AHRQ safety surveys.  Contact us!


CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

What the AHRQ guidance means for providers and their patients. 11

Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

New CPS report seeks to raise awareness of safety concerns in the EMS community. 16


  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

AHRQ Communication and Optimal Resolution Toolkit

AHRQ has released a very useful toolkit to help health care providers communicate with patients/family members after an unexpected event that caused harm. The “Communication and Optimal Resolution” (CANDOR) toolkit includes step-by-step guidance, forms, videos and other resources to assist providers through the entire process, beginning with identification of an error to resolution with those involved.

Download the free toolkit here.


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.