Office of Inspector General releases first report to explore participation within the PSO program

10.23.19

On September 25, 2019, the U.S. Department of Health and Human Services’ Office of Inspector General issued its report entitled “Patient Safety Organizations:  Hospital Participation, Value, and Challenges”.  The study of current PSOs and their participating hospital providers was conducted in part to determine how well the PSO program is progressing and what measure of success and confidence the participating providers believe they have received as a result of the Patient Safety and Quality Improvement Act of 2005 (PSQIA) and corresponding PSO program. 

The HHS IG Office surveyed 600 acute care hospitals composing a nationally representative sample of all hospitals as well as all of the federally listed PSOs, and as the Agency for Healthcare Research and Quality (AHRQ) staff who had oversight of the program from 2009–2017. 

In sum, the Report is very favorable for the PSO program and the benefits it has provided to increase patient safety and quality efforts.  Eighty percent of the hospitals found that the feedback they receive from the PSO with which they participate is helpful in assisting plan for future patient safety events.  However, one of the challenges noted is that there is still not a robust national system within which PSOs report there information and findings and has therefore been a slowed process toward national learning from these events within the multitude of PSOs.

In addition, 42 percent of the PSOs at the time of the survey did not use Common Formats and therefore could not contribute to the national database.  The IG Report recommends that AHRQ consider allowing PSOs to contribute data in formats other than Common Formats. 

The IG report notes that “Congress intended for the PSO program to be unique and powerful among patient safety programs.  It is the first and only nationwide program that offers legal protections for providers to disclose patient safety events and learn from them.  Where providers were once reluctant to discuss patient safety events for fear of litigation, they may now seek expert analysis from PSOs and discuss these events with peers that are fellow PSO members.”  

Within the findings, the report also concludes that hospitals working with a PSO overwhelmingly experience improved patient safety, feedback and analysis on patient safety events which have helped prevent future events from occurring, as well as enabling them to better understand the cause of the events.  Furthermore, “[a] PSO may use its analysis of aggregate data to show members how their data compare to those of their peers  …” and many found “value in the ability to learn from other organizations.  Working with a PSO allows hospitals to draw on the shared knowledge of their fellow member-hospitals through peer-to-peer learning that would otherwise not be available to them.”  

It is one of the best vehicles ever created to assist with improved patient safety and to decrease the number of deaths and patient harm events across the healthcare spectrum.  With that said, there is, as with most endeavors, continued room for improvement.  The IG report adds support for further growth and expansion of the PSO program and the important work that it enables.

To access the Inspector General’s full report, go here.