Working With A PSO: One Approach (Text Description)

At top right of diagram: A box labeled “Abbreviations.” This contains five lines with explanations of abbreviations used in the diagram:

(First line) “PSO = Patient Safety Organization”
(Second Line) “PSWP = Patient Safety Work Product”
(Third Line) “PSES = Patient Safety Evaluation System”
(Fourth Line) “PSOPPC = PSO Privacy Protection Center”
(Fifth Line) “NPSD = Network of Patient Safety Databases”

At top center of diagram: A long rectangle, labeled “Patient Safety and Quality Information” is connected by a short, black downward arrow to:

A long rectangle labeled “Information Triaged by Provider.” This is connected by a downward black arrow that splits horizontally to the left and right, pointing down on the left to a box labeled “Information Eligible to Become PSWP” and down on the right to a box labeled “Information Not Eligible to Become PSWP.”

Below left of “Information Triaged by Provider”: The box “Information Eligible to Become PSWP” contains two distinct bullet points:

[dash bullet] “Could improve safety, quality, or outcomes of health care;” and
[dash bullet] “Assembled or developed solely for reporting to PSO (not for other purposes)”

This box is connected by a downward black, right-sloping arrow that points to a box labeled “Provider PSES” in the diagram's center.

Below right of “Information Triaged by Provider”: This box, labeled “Information not Eligible to Become PSWP,” has a subtitle “(Remains Outside Provider PSES).” The box contains two bullet points, the latter of which has three second-level bullet points:

[1st-level dash bullet] “Excluded by definition of PSWP ([Footnote] 1); or”
[1st-level dash bullet] “Collected or developed for purposes other than reporting to a PSO, such as:”
    [2nd-level dash bullet] “Corporate and external recordkeeping requirements”
    [2nd-level dash bullet] “Inspection, survey, or external reporting requirements (Federal or State)”
    [2nd-level dash bullet] “Other business purposes, such as claims, etc.”

From this box, a dashed red arrow—aimed diagonally down and leftward—points to a lower central box labeled “Provider PSES.” The arrow is labeled by the text “Provider may enter a copy of ‘ineligible' information into its PSES ([Footnote] 2)”

Box labeled “Provider PSES” contains four bullet points:

[dash bullet] “Date and document incoming information upon entry”
[dash bullet] “Analyze or deliberate ([Footnote] 3)”
[dash bullet] “Option: Remove incoming information before reporting to the PSO ([Footnote] 4).” There is a dashed red arrow pointing back—horizontally to the right, then straight up—from this bullet point to the box “Information Not Eligible to Become PSWP.”
[dash bullet] “Prepare and report incoming information to PSO.”

A solid black arrow points diagonally down and rightwards, from the lower left border of this box to the box just below it (“PSO PSES”). This arrow is labeled by the text, “Information reported to the PSO, or accessible by the PSO, pursuant to functional reporting, is PSWP ([Footnote] 5).”

Box labeled “PSO PSES” contains three bullet points:

[dash bullet] “Conduct required patient safety activities”
[dash bullet] “Provide feedback to provider PSES”
[dash bullet] “Prepare data to submit to PSOPPC”

A black arrow points diagonally down and leftward, from the box's vertical left border to a rectangle labeled “PSOPPC;” while another black arrow--labeled “Feedback to provider by PSO is PSWP” points diagonally up and rightward from the box's top right border to the box “Provider PSES.”

Rectangle labeled “PSOPPC,” at lower left of diagram, has a black arrow pointing horizontally rightward to a rectangle labeled “NPSD.” This arrow is labeled “Nonidentifiable Patient Safety Event Data.”

Footnotes, below diagram:

1. Paragraph (2)(i) of the PSWP definition under the Patient Safety Rule (42 CFR§3.20) lists the types of information that are not eligible to become PSWP.
2. Never report to the PSO, as PSWP, originals of ineligible information. Only copies of ineligible information or information dropped out of the PSES can be reported to the PSO.
3. When analysis and deliberations are conducted in the PSES, PSWP protections will apply immediately; the drop-out provision does not apply.
4. Verify that incoming information is eligible to be PSWP before reporting to the PSO. The drop-out provision applies only to incoming information that has not yet been reported to a PSO. The provider must document the date and act of removing incoming information from the PSES.
5. The drop-out provision cannot be applied to information that has been actually or functionally reported.

AHRQ Publications Information is on the lower right, directly to the right of the Footnotes:

At top: Small AHRQ logo.

Middle line: AHRQ Pub. No. [Publications Number] 13-PS018

Bottom line: March 2013

Return to Frequently Asked Questions