Why Are Some Organizations Reluctant to Participate in a PSO?


July 2013

Patient Safety Organizations (PSO) were created by the federal Patient Safety and Quality Improvement Act of 2005 (PSQIA) to encourage health care providers to share and learn from a collective pool of data that is legally protected from discovery during litigation. Many organizations with a mature safety culture understand the value of participating in a PSO, but unfortunately some organizations are still not on board.This reluctance has been a surprise to many in the patient safety field, but there may some misunderstandings about PSOs that are preventing organizations from benefitting from participation.

Is this just another fad?

There has been tremendous work focusing on quality and patient safety over the past decade. Those who work in quality, patient safety, and risk management have had to adjust to the constant change in improvement models over the years, and have become skeptical about adopting new models, ideas, or processes until they have been proven to be lasting and effective. This is understandable because jumping from one change model to another is not effective. It is recommended that an organization adopt a standard change model and bring in principles from other models as appropriate. For example, a hospital may primarily use a lean six sigma model for performance improvement, but use a rapid cycle PDSA (plan, do, study, act) when improving a process with multiple steps.

Organizations should view PSO participation as a way to augment their current processes, not replace. When developing improvement strategies, organizations often question, “Is this a problem for anyone else? If so, what are they doing about it?” PSOs offer that safe platform for sharing information and best practices in a protected environment.

CHPSO offers lessons learned through Patient Safety News as well as providing feedback to individual member organizations. Educational webinars are offered at least monthly to provide valuable information and instruction in ways organizations can build a culture committed to patient safety.  The CHPSO website has a “useful tools” section with guidelines and forms shared by other members to assist in causal analysis. This resource center will soon contain additional “ready-to-use” information.

Skeptical about legal protections

Some organizations question the strength of the protections promised by the PSQIA. Some recent court cases have attempted to challenge these protections and the outcomes have been reassuring to many. A Kentucky trial court in late 2011 ruled that the federal PSQIA protections superseded state peer-review law and that patient safety work product (PSWP) that had been reported to a PSO was protected from discovery. The plaintiff attorney requested the disclosure of various documents, including a Root Cause Analysis (RCA). Under state law, the documents would have been discoverable because they were not subject to attorney-client privilege. For full details of this ruling and other cases, visit the “Legal references” section of the CHPSO website.

This is one of the first cases in which a state court upheld PSQIA protection and will likely set precedence for future challenges.

Overwhelmed with data reporting

With so many other mandatory reporting requirements, organizations may think that voluntary reporting to a PSO is too much of a burden. In addition, patient safety and risk management professionals are busy responding to the events within their institution and may not have the time or resources for external reporting. It is easy to overlook the ways PSO participation may actually save on time & resources.

By learning from others, facilities can standardize and streamline processes that will make them more efficient and productive, as well as provide safer and better quality care to their patients. Instead of spending time responding to events that have already occurred, patient safety, quality, and risk professionals can devote their efforts to prevention.

CHPSO is working with incident reporting vendors to encourage more automation in the PSO reporting process. Some systems, like Midas, have already successfully developed these modules and are working to remove as many manual steps in the process as possible.

Not mandatory…Yet

Reporting of event data to PSOs was originally designed to be voluntary. However, some agencies already understand the value of learning from the data captured by PSOs. The Health Information Technology for Economic and Clinical Health (HITECH) Act and the Office of the National Coordinator for Health Information Technology (ONC) encourage reporting of health IT related safety events through PSOs, rather than create another federal agency to collect, aggregate, and analyze this information.


Not Just Adverse Events: The Bigger Picture from Four Years as a PSO. August 2012. Risk Management Reporter, ECRI Institute, Vol. 31, No. 4)