Ellen Flynn RN, MBA, JD AVP, Safety Program Vizient PSOE

Ellen Flynn RN, MBA, JD AVP, Safety Program Vizient PSOE
Patient Safety Organizations (PSOs): What Every Physician Group and Ambulatory Services Provider Needs to Know Ellen Flynn RN, MBA, JD AVP, Safety Program Vizient PSOE

Speaker Bios Ellen M. Flynn RN, MBA, JD Associate Vice President, Safety, Vizient In her role at Vizient, Flynn has oversight of the Vizient Patient Safety Organization (PSO), leading patient safety activities provided by the PSO to help members improve patient safety, health care quality and outcomes. She works with members on topics such as “Just Culture,” “High Reliability,” “Human Factors” and “Culture of Safety.” Michael R. Callahan, Katten Muchin Rosenman LLP Michael R. Callahan assists hospital, health system and medical staff clients on a variety of health care legal issues related to accountable care organizations (ACOs), patient safety organizations (PSOs), health care antitrust issues, Health Insurance Portability and Accountability Act (HIPAA) and regulatory compliance, accreditation matters, general corporate transactions, medical staff credentialing and hospital/medical staff relations. Jill Olinick PT, Manager Safety Events, Mercy Center for Quality and Safety Jill Olinick provides leadership oversight of the event reporting system, facilitating any changes to the system and focusing efforts on improving patient safety based on event review trends. Jill is responsible for PSO relations and engaging the right teams in event review discussions as well as development of processes to improve event reporting and response. She has over 25 years of healthcare experience that includes staff PT, leadership and operations as well as initiation of Safe Patient Handling programs, Work Safety and Ergonomics. Jill holds current certification in ergonomics and maintains her PT license. She is a member of ASPPS. Priya Khatri MBA, MPH, Director, Strategic Analytics and Performance Improvement, UT Physicians Priya Khatri works in strategic analytics and performance improvement at UT Houston Health Science Center. She is a member of the Patient Safety Leadership team that led the installation and launch of safety event reporting. Currently, Priya helps manage the safety event reporting system. She works with the outpatient practice to identify opportunities for improvement, implement interventions, and spread best practices across clinics.

Disclaimer The opinions expressed in this presentation do not reflect the official position of the Agency for Healthcare Research and Quality (AHRQ) or the Office of Civil Rights (OCR). ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient. Vizient PSO Presentation │ February 2019 │ Confidential Information

The Vizient PSO provides a full spectrum of safety services
For licensed providers Collaborate with peers Gain federal discovery protection Identify improvements with patient safety activities Submit data to the Network of Patient Safety Databases Meet ACA requirements ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Vizient PSO: What makes us different?
Patient Safety Pioneer Long history of turning patient safety event data into actionable information to improve outcomes and collaborating with members to define leading patient safety practices since 2001 Robust event reporting format and taxonomy developed in 2001 Credibility Component of Vizient Inc., the nations largest member owned healthcare performance management companies Patient safety learnings regularly highlighted at the AHRQ annual PSO meeting, IHI Patient Safety Congress, and IHI National Forum meetings, published in peer review journals and available to the healthcare community on the Vizient website Over 200 healthcare providers collaborate with Vizient PSO to improve patient safety outcomes I am thrilled to have the opportunity to be here today and tell you a little about Vizient’s PSO and the success we have had improving patient safety outcomes ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Patient Safety Organization key takeaways
PSOs offer privilege and confidentiality protections that are national in scope PSOs aggregate data to identify patterns, trends, and the underlying causes of infrequent, but often tragic, adverse events faster than individual organizations PSOs can convene its reporting providers in a protected environment to leverage learning and improvement PSOs collect data in a standard format to allow for meaningful comparisons amongst similar providers Key take aways from the presentations today Working with a PSO offers privilege and confidentiality protections for voluntary patient safety activities –in most states hospitals have protections for patient safety and quality improvement activities, yet not all providers in hospitals are equally protected such as nurses and pharmacists, outpatient physician groups or health system activities might not be protected and protections only apply in state law. The patient safety act protections for working with a PSO are much broader protection than any state law and there is no way to accidentally waive the protections that occurs with many state law protections By many providers sending their data to a PSO with PSO—PSOs are able to identify trends patterns and underlying causes of events must more quickly and in this presentation –I will tell you about how we are using huddles to accelerate the pace of identification and sharing with our members As Lifespan –one of our PSO members present today will tell you today –our members work together as an improvement community and accelerate the pace at which they improve patient safety—one of my favorite examples of this is our behavioral health project in medical settings project last year. Members agreed this was a real opportunity, we formed a group, reviewed the data and started working on solutions. One of our PSO members who was on the call told us about the great work being done in this area at Yale. It turned out one of our members had a contact at Yale who was leading the work and he graciously agreed to share information on their behavior intervention teams which was the perfect solution for the issues we saw in the data. Even though not a PSO member, the Yale physician joined our group and helped other members understand their work. We developed a tool kit that our members implemented and it has improved outcomes. The work has been recognized at AHRQ and IHI. I loved how a physician from froedtert described how the process worked and how we were able to get to the best practice at Yale because of our improvement community All organizations and patients will benefit from organizations working with a PSO to acclertate the pace of learning and improvement in your organization and I would love if you would consider Vizient ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

2019 Summary of event types resulting in high harm (Greater than 18 years)
Behavioral management Suicide (post discharge or ambulatory treatment) Elopement Violence (self and others) Forensic patient care Unexpected Cardiac and Respiratory arrest ED (boarders) Medical Surgical Units Procedural areas Radiology Telemetry patients (alert fatigue) Critical result reporting delays Provider-patient communication errors/delays relative to results Delays in treatment (Stroke, Sepsis) Falls (Post-fall treatment) Maternal complications Medication safety Anticoagulants Opioid overdose (pain management) Procedural Sedation Pressure ulcers Readmissions from ED and Acute care Vizient collects patient safety work product from our members and reviews high harm events to identify opportunities for improvement We also receive phone calls from our members about specific safety issues and then review the data, bring members together and develop what is needed to help members improve care. Next year, we will be expanding how we identify safety opportunities and we willl include …member calls, huddle topics, and patient safety work product reported. We are casting our net wider to find relevant safety opportunities. This year we will also develop a list of contributing factors and use that list to design our PSO officer training Vizient PSO Data from July 1, 2017 – June 30, 2018 ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Collaboration within PSES
Vizient PSO patient safety activities drives improvement in ambulatory providers Education Topical safety webinars High reliability outcomes, culture of safety and CANDOR Alerts, Tool kits, White papers Collaboration within PSES Ambulatory huddles and topical safe tables Individual feedback reports with comparative data Safe learning space within licensed provider organization and with affiliated providers Networking Semiannual in-person meeting Quarterly, Power learning – user group, Listserv Leading practice advisory groups Operations Ambulatory reporting format and taxonomy SFTP set up for secure data submission events, root cause analysis, failure mode effects analysis, peer review PSES documentation Privileged and Confidential ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

2019 Vizient PSO Calendar of Webinars
Month HRO and Safety Culture* Topical Safety* Safe Table PSO operations January January 22: Standard work: Changing role of the manager to sustain improvements January 16: Closing the loop on abnormal laboratory test results (2PM Central Time) (90 min) January 24: PSO Orientation February February 19: Redefining Patient and Provider Relationships February 7: Closing the loop on incidental radiology findings (90 min) February 27: PSO Power Learning March March 19: Transforming the mid-level leadership role in HROs March 14: Managing the risks associated with concentrated insulin March 12: Procedural Sedation March 6: Case Law updates April April 8-10: Semi-Annual In-person PSO Meeting April 3: Neuromuscular Blocking Agent Administered to an Unventilated Patient April 11: Forensic patient care April 17: PSO Orientation May May 7: Working with a PSO in physician and other ambulatory care practices to improve patient safety outcomes May 9: Procedural Sedation (90 min) June June 18: Role of event reporting June 13: Preventing wrong site procedures June 27:Suicide: Post discharge and during outpatient treatment June 5: PSO Power Learning July July 11: Vaccines August August 20: Safety science August 8: Suicide: Post discharge and during outpatient treatment August 14: PSO Orientation September September 16-18: Semi-Annual In-person PSO meeting at Vizient Summit September 12: Pressure Injury September 10: Handoffs: Improving the communication between departments October October 15: Culture of safety October 10: Handoffs: Improving the communication between departments (90 min) October 23: PSO Power Learning November November 5: Comprehensive safety program November 14: Cardiac and Respiratory arrest outside the ICU November 6: Case Law Update December December 3: Change management December 5: Neonatal morbidity and mortality December 12: Readmission to the ED Vizient Presentation │ June │ Confidential Information

Vizient PSO Safety Huddle
If it happens at one organization can happen at any organization without the right controls. Investigate the issue and opportunities Prevent by taking action internally Share opportunities for prevention Discuss safety issue with peers Jaundice meters “0” meaning out of range indication may be misinterpreted as normal leads to recall. Skull clamps Breakage of the skull clamp screw pin during the procedure. Mobile computer workstations Prevent fires by creating a cleaning, inspection and maintenance schedule. Go-LYTELY Evaluate current nursing reconstitution practices to prevent the risk of dosing errors. Umbilical cord security tags Determine if your tags have a one-year limited warranty and fail to operate after this period. The purpose of this work is to improve patient safety, healthcare quality and outcomes. The huddle focuses on system safety issues because alerting other members to these types of events will promote learning and improved outcomes. Bringing safety leaders together to conduct deliberations and analysis will help members identify solutions that they might not think of on their own. ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Vizient® Patient Safety Organization (PSO) Aggregate Analyses and Leading Practice Documents
2013 2014 2015 2016 2017 2018 2019 Retained Surgical Sponges Health IT-related Safety Events Assaults by Patients in Hospitals System Wide Management of Clinical Alarms Discharge care for patients on DOACs Burns from Light Source Cables Closing the Loop on incidental radiology findings Accurate Perioperative Orders Closing the Loop Abnormal Labs Guidewires Unintentionally Retained During CVC Ventilator-Related Adverse Events New Standards for Enteral Connectors Management of Cardiac/Physio- logic Alarms Periprocedural care for patients on DOACs Jaundice Meter Procedural Sedation Opioid Safety Suicide post discharge or in outpatient tx Suicide Prevention Surgical Specimen Events Robotic-assisted Surgery Health IT-related medication safety Fall Prevention Management of Behavioral Issues Violence Prevention Managing Behavioral Issues in Ambulatory Concentrated Insulin Hand-off Communication ED to Floor Prevent injury from skull clamps Unexpected cardiac/respiratory arrest outside ICU Errors, Omissions and Delays in Diagnosis Surgical Specimen Management: A Descriptive Study of 648 Adverse Events and Near Misses Preventing air embolism from central venous catheters Anticoagulants Periprocedural Care Coordination Air Embolism Dental Events GoLYTELY Reconstitution ED Readmission Surgical Specimen Errors TBD ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

To improve patient safety and reduce medical errors by creating a ‘‘culture of safety’’ to share and learn from information related to patient safety events Goal 1: Patient Safety and Quality Improvement Act 2005 ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

To promote health care providers’ accountability and transparency through mechanisms such as oversight by regulatory agencies and adjudication in the legal system. Goal 2: Patient Safety and Quality Improvement Act 2005 ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Provider (non-PSES) Operations
Ambulatory practices can create a safe culture of learning by working with a PSO Provider (non-PSES) Operations Open, honest, transparent communication with patient, family, care team, regulators (consistent with HIPPA requirements) Event disclosure and possible reconciliation with patient and family Support for patient, family and caregivers Provider PSES Event reporting, RCA, FMEA, peer review Deliberation and analysis Sharing lessons learned within provider and with affiliated providers Action plans Privileged and Confidential ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Patient Safety Organizations (PSOs): What Every Physician Group and Ambulatory Services Provider Needs to Know Michael R. Callahan Katten Muchin Rosenman LLP Chicago, Illinois

Environmental Overview
Plaintiffs are looking for as many deep pockets as possible in a malpractice action Hospital has the deepest pockets Tort reform efforts to place limitations or “caps” on compensatory and punitive damages have increased efforts to add hospitals, health systems, physician groups and any other providers involved in the alleged negligent acts as defendants Different theories of liability are utilized Respondent Superior Find an employee who was negligent

Environmental Overview (cont’d)
Apparent Agency Hospital-based physician, i.e., anesthesiologist, was thought to be a hospital employee by the patient and therefore hospital is responsible for physician’s negligence Physician group or ancillary provider which is owned, managed, controlled or affiliated with the hospital and is marketed as such could be treated as an apparent agent Doctrine of Corporate Negligence Hospital, CIN, ACO, PHO, ancillary provider issued clinical privileges to a practitioner who provided negligent care who they knew or should have known was not competent Industry shift from reimbursing providers based on the volume of services provided to the value of services obtained – must satisfy quality outcomes/metrics in order to be paid

Greater transparency to general public via hospital and other provider rankings, published costs and outcomes, accreditation status, physician licensure status, etc. Medicare Shared Savings Program ACOs which require compliance with 33 identified quality metrics in order to share in savings Medicare Value Based Purchasing standards based on quality metrics MACRA/MIPS Payment denials for growing list of never events, i.e., wrong site surgery Payment denials for hospital acquired infections Payment penalties tied to high readmission rate

Pay for performance standards required by managed care payors This “volume to value” shift will require continuous and ongoing monitoring of provider’s compliance with these quality metrics and outcome requirements which will result in the generation of sensitive quality, peer review and risk data, reports and analyses Hospitals and physicians are being required to report their outcome data to state and federal agencies which are made available to the public resulting in greater transparency for comparative shopping based on quality and price

All of this and more information must be taken into consideration when appointing, reappointing, credentialing, privileging and monitoring physician/APN/PA performance so as to assess current competencies to perform all clinical privileges at hospitals, managed care organizations, nursing homes, clinics, surgicenters, clinically integrated networks, etc., and to comply with quality outcome and metrics requirements The challenge is to utilize and maximize the available state and federal privilege protections in order to protect this information from discovery and admissibility into evidence

Complete view of an operational CIN
COO CFO CMO CNO COO Hospital(s) Primary Care Physicians Public Health Agencies Ancillary Providers Long Term Care Post Acute Care Hospice Home Care Specialists PHO Payer Partners

Background Legislative History
Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) Signed into law July 29, 2005 Final rule released November 21, 2008 Rule took effect January 19, 2009

Background The goal of the PSA was to improve patient safety by encouraging voluntary and confidential reporting of health care events that adversely affect patients. To implement the PSA, the Department of Health and Human Services (HHS) issued the Patient Safety and Quality Improvement Rule (Patient Safety Rule). The PSA and the Patient Safety Rule authorize the creation of PSOs to improve quality and safety through the collection and analysis of aggregated, confidential data on patient safety events. This process enables PSOs to more quickly identify patterns of failures and develop strategies to eliminate patient safety risks and hazards.

Background The PSA: Provides privilege and confidentiality protections for information when providers work with Federally listed PSOs to improve quality, safety and healthcare outcomes Authorizes establishment of “Common Formats” for reporting patient safety events Establishes “Network of Patient Safety Databases” (NPSD) Requires reporting of findings annually in AHRQ’s National Health Quality / Disparities Reports

Equal consistent enforcement Nationwide and Uniform
Patient Safety Act Learning environment Facilitates development of a safe and protected learning space where providers focus on improving care versus legal or disciplinary implications of findings Allows provider organizations to maintain a “Just Culture” of accountability with deliberate PSES set-up Equal consistent enforcement Enables all licensed providers to receive equal protections Supports new healthcare models that place more and more responsibility on non-physician healthcare providers and corporate parent organizations Nationwide and Uniform Enables healthcare providers to collaborate and learn from quality, safety and healthcare outcome initiatives that cross state lines without legal ramifications ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Meaningful comparison Flexible Participation
Patient Safety Act Early recognition Enables the PSO to detect patterns and trends not readily visible in patient safety data of a single organization or small health system Meaningful comparison Encourages data collection, aggregation and analysis amongst similar providers in a common format to allow for meaningful comparisons and easier identification of improvement opportunities Flexible Participation Allows providers to negotiate with PSOs about the quantity and type of data reported as well as the type of analysis and feedback provided by the PSO ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Patient Safety Activities
Efforts to improve patient safety and the quality of health care delivery The collection and analysis of patient safety work product The development and dissemination of information with respect to improving patient safety, such as recommendations, protocols, or information regarding best practices The utilization of PSWP to encourage a culture of safety and provide feedback and assistance to effectively minimize patient risk The maintenance of procedures to preserve confidentiality with respect to PSWP The provision of appropriate security measures with respect to PSWP The utilization of qualified staff Activities related to the operation of a PSES and to the provision of feedback to participants in a patient safety evaluation system.

What is Patient Safety Work Product?
Must be created in PSES PSA Requirements PSWP Reports Oral and Written Statement Data Records Memoranda Deliberation and Analysis Key dates must be documented Data which could improve patient safety, health care quality, or health care outcomes Data assembled or developed by a provider for reporting to a PSO and are reported to a PSO and/or which constitute Analysis and deliberations conducted within a PSES Data developed by a PSO to conduct patient safety activities ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Data collected for another reason Discharge information
What is Not PSWP? Not PSWP Data removed from PSES Medical record Data collected for another reason Billing Other original record Discharge information Information collected, maintained, or developed separately, or exists separately, from a PSES. Data removed from a patient safety evaluation system Data collected for another reason Mandatory adverse event report ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Patient Safety Evaluation System (PSES)
PSES is the collection, management, or analysis of information for reporting to or by a PSO. A provider's PSES is an important determinant of what can, and cannot, become PSWP. PSES Equipment Staff Policies and Procedures Physical Space Virtual space ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

PSA Privilege and Confidentiality Standards Prevail Over State Law Protections
The privileged and confidentiality protections and certain restrictions on disciplinary activity supports development of a Just Learning Culture State Peer Review Patient Safety Act Limited in scope of covered activities and in scope of covered entities State law protections do not apply in federal claims State laws usually do not protect information when shared outside the institution – considered waived Consistent national standard Applies in all state and federal proceedings Scope of covered activities and providers is broader Protections can never be waived PSWP can be more freely shared among affiliated providers throughout a health care system PSES can include non-provider corporate parent ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

PSWP is Privileged Not subject to: Subpoenas or court order Discovery
FOIA or other similar law Requests from accrediting bodies or CMS Not admissible in: Any state, federal or other legal proceeding State licensure proceedings

Direct identifiers removed Valid written authorization
PSWP is confidential and not subject to disclosure with limited exceptions In camera inspection Direct identifiers removed Valid written authorization Confidential Criminal activity Approved disclosure Research Accrediting Bodies Business Associates Non –identifiable PSWP Provider to PSO Contractor of a Provider FDA Affiliated Providers Equitable Relief of Reporter Another PSO or provider Please see Patient Safety Final Rule for a complete description Need protective order for work product Sanctioned by the secretary of the HHS and HIPAA Privacy Rule Compliant No further disclosure and limits on use Patient safety activities Further disclosure limited to patient safety activities No further disclosure Patient safety activities and no further disclosure Patient safety activities ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Peer Review Protections For Physician Groups and Ancillary Providers

Complete view of an operational CIN
COO CFO CMO CNO COO Hospital(s) Primary Care Physicians Public Health Agencies Ancillary Providers Long Term Care Post Acute Care Hospice Home Care Specialists PHO Payer Partners

What is “Peer Review” The term “peer review” is a catch-all reference used by hospitals and other providers to cover and describe a broad range of activities, discussions, analyses and work product involving: Quality assurance and improvement Performance improvement Ongoing monitoring under OPPE/FPPE and other quality standards Tracking outcomes and compliance with quality metrics Monitoring, proctoring, investigating, analyzing and correcting substandard practices and disruptive behavior Similar remedial measures and efforts to evaluate the current competency of physicians, advanced practitioners, nurses and other healthcare practitioners

What is “Peer Review” Consequently, if these peer review activities, which is a subset of patient safety activities, are identified, collected, analyzed and utilized for the purpose of improving patient care by the provider as subscribed within the provider’s PSES policy, all of the work product and discussions can be treated as PSWP The Final Rule states that PSWP can be used for peer review, credentialing and other peer review and quality purposes within a single legal entity, i.e., hospital, physician group, without limitation if used for patient safety activities BUT an employer may not take an adverse employment action against an individual based on the fact that the person reported PSWP in good faith to a provider with the expectation that it would be reported to a PSO or if reported directly to the PSO

Asserting PSA and/or State Peer Review Protections
Keep in mind that physician groups and other providers may also be able to assert the privileged protections under state law You need to review state statutes and the case law in order to determine the scope of covered entities and covered activities Any state statutes focus on whether the activity or work product in dispute were involved or is produced by a “committee” thereby lending the scope of privilege protections Depending on the document in question, both the state and the PSA privilege protections could apply although PSA protections usually are broader You cannot also assert attorney-client work product privilege for these materials

Sharing PSWP Physician/ancillary provider PSWP can be shared by and between affiliated providers Identifiable PSWP may be freely “used” within the physician group or other ancillary entity – a disclosure exception is not required Physician identifiable PSWP may be “disclosed” to other affiliated entities but you must some how obtain the prior written authorization of the provider. Options include: Specific written authorization language in the physician appointment/re-appointment application Specific written authorization language in the employment agreement Use of a specific form each time physician/provider PSWP is disclosed

Need to Choose a PSWP Pathway
Your PSES policy should identify in some detail all of the patient safety activities, reports, analyses, peer review activities, etc., which the provider wants to treat as PSWP. Reporting Pathway PSWP is either electronically or physically reported to APSO. PSWP is “functionally reported” to the PSO. Deliberations or Analysis Pathway The definition of PSWP also includes any data, reports, records, memorandum, analyses or written or oral statements which… identify or constitute the deliberations or analysis of, or identify the fact of reporting to a [“PSO”] (Emphasis added). Any PSWP which is not physically or functionally reported to a PSO should be categorized as deliberation or analysis within the PSES policy.

Need to Choose a PSWP Pathway
PSWP which is deliberation or analyses automatically becomes PSWP when collected within the PSES and cannot be “dropped out” and used for other purposes. PSWP which is deliberation or analyses does not need to be reported to a PSO in order to be treated as privileged and confidential. Because all of the reported Appellate Court cases, including those in which the information was deemed to be PSWP, are actual reporting to the PSO cases, serious consideration should be given to reporting peer review information to a PSO.

Working with a PSO in Physician Practices - System Perspective
Jill Olinick, PT Manager Safety Events Mercy Health

About Mercy Hospitals & Ambulatory Sites Medical Staff & Co-workers
Utilization FY18 3,331 staffed beds 25,081 births 178,104 surgeries 195,151 inpatient discharges 10,290,454 outpatient visits 738,977 ED visits Hospitals & Ambulatory Sites 29 acute care hospitals 4 heart hospitals 3 rehab hospitals 2 children's hospitals 2 orthopedic hospitals 1 virtual care command center 903 physician practices 345 clinic locations 12 outpatient surgery centers 35 urgent care sites 29 convenient care centers Medical Staff & Co-workers 45,000+ co-workers including: 2,400+ integrated physicians 1,500+ integrated advanced practitioners as of February 2019 (FY18 Utilization includes Mercy Fort Scott) Annual Community Update | 42 Headquartered in St. Louis, Mercy is one of the largest Catholic health systems in the US, serving millions each year over a multi-state footprint through touchpoints including outreach ministries and virtual care. About Mercy 4 states, with outreach ministries in 3 others 42 Total hospitals which includes 17 CAH and a virtual care facility Over 900 physician practices 64 total convenient and urgent care locations Just want to acknowledge much of the initial work for establishing our PSES and regional clinic focus was completed prior to me being in my current role. I am just privileged to be the messenger of the foundation that was laid and am blessed to be able to continue to work with an awesome team.

Creating and Establishing Our PSES
Initial Steps Education - learned via multiple sources Gathered information current status and activities Reviewed AHRQ and Vizient information and checklists Identified Senior Leader Sponsors in all regions Identified key stakeholders Patient Safety Legal Risk/Claims Quality Physician leadership Became educated about the act from AHRQ, Outside Legal Expertise, MHA, Vizient and various publications Activities related to pt safety, event investigation, peer review etc and any affiliated meetings (initially hospital focused) Checklist for what all needed to be done to establish PSES and reporting to PSO Ministry, region senior leaders Vizient PSO Presentation │ February 2019│ Confidential Information

Creating and Establishing Our PSES
Workout to establish plan Identified champions Identified key teams needing communication and education Timeline and process map Policy Initiation Education Roll-out Ongoing revision as we continue to learn Pt safety leaders at facilities, risk team members, legal team members Specialty councils, senior leaders at facilities, quality teams, patient safety teams, key leadership meetings, front line leaders and coworkers – Initial policy drafted and several iterations, now in revision since been 3 years and as we have learned more and discussed potential inclusions and exclusions based on experience We also know we have an opportunity improve ongoing ed and communication with current as well as with new leaders, coworkers etc (reaching now to service line ministry wide groups) and expanded clinic education Vizient PSO Presentation │ February 2019│ Confidential Information

Clinic Co-Worker Reporting and Engagement
To Engage: Safety Manager for the clinic established relationships Visited each clinic Followed up on both the visits and the reports NOT punitive or finger pointing Tools and education developed Consistent message This clinic region hosts: conferences 2x per year 90 min – managers and safety partners from each location; whole day training for new clinic practice managers around the safety program; new safety partners ½ day training Prior to our current reporting system and joining the PSO in 2016, 1 of our 3 regions took the initiative and began the work engaging staff and physicians in safety awareness and getting comfortable with reporting (300 clinics in East now) Consistent message: Can’t help if don’t know Safety presents at clinic manager meetings Goal to replicate in our other regions

Engagement Established committee: Membership: Primary care physician
Specialty care physicians Clinic leadership Lab, Pharmacy, Education, Other Responsibilities: Review events and opportunities, address safety concerns Develop standardized process/tools and educate Collaboration to fix not just leave it to each individual location (team) Celebrate “Great Catches” reps included and opened up to anyone wanted to join – MAs, office managers physicians, RNs The committee responsibilities are to address safety concerns, develop and correct processes and/or policies, approve tools, celebrate “Great Catches”, provide education, work with other committees regarding safety, support and promote clinic safety work. Examples of tools: Emergency preparedness checklist, fall prevention practices, v Vizient PSO Presentation │ February 2019│ Confidential Information

Quarterly Reporting Trend Specific Region
East Clinic Region UCL(3) LCL(3)

Quarterly Reporting Trend Overall
40% of all reports are from the region that has had this focus Clinic reporting originally 3.9% of all our system reports now (most recent 4 qtrs.) 4.3% of all Safety and unsafe conditions reports 99% of our reports are submitted to the PSO (check this stat) Vizient PSO Presentation │ February 2019│ Confidential Information

Provider Reporting and Engagement
Recent increases in provider reporting to include self-reporting Region Follow – up and resolution Developed quality/safety committees by specialty area (Adult, OBGYN, Peds, Safety) –– better adoption and engagement Med safety task force (pharmacists from retail side participate) – review Ministry wide Legal visited with the various councils on the PSO protections –– better together Initiated participation in PSO Best Practices Work, Safe Table Topics, etc. Events are discussed at safety committee and participate in RCAs Believe this is largely due to follow up and understand its about the pt, where to go, report, and how to get resolution and turnaround – increased participation on committees by providers because they are seeing this; onboarding stresses use of SAFE and they are utilizing Committee morphed into this - QSV – presented, discussed opportunities and agreed to std – led to better adoption of practices and overall engagement still have opportunities to understand the benefits and the importance of transparency within, sharing between clinics and regions From a ministry wide perspective, one of our attorneys visited with our various specialty councils to explain the PSO protections Really in the last 6 months we’ve been able to engage several of our physicians and leaders to participate in some of the PSO Best Practice work Important for the providers to be part of the event discussion and review Vizient PSO Presentation │ February 2019│ Confidential Information

Outcomes and Focus Regional
Review of vaccines and put together tool for auditing Safety rounds in the clinics by a safety manager Increased participation with huddles for clinic safety designees Ministry wide Regular meetings with the regional safety leaders Ministry steering committee – quality and safety Replication of regional strategy Review of vaccines and put together tool for auditing – first step, then reported out to committee, this led to: On safety rounds - uses a checklist – OSHA, CLIA, Vaccine Safety etc, meds, equipment, infection prevention, added/modified as identified opportunities) – and review SPH Regular meetings - Sharing of trends, including specific event sharing and follow up actions Steering committee - Targeted goals and process implementation across all regions We also want replicate to the other regions as much as possible Vizient PSO Presentation │ February 2019│ Confidential Information

Opportunities Reporting of falls
More robust follow up and discussion from practice managers Co-worker communication and follow-up Peer review Leveraging PSO participation Still timid with our fall reporting and follow up (quick response to indicate no blame instead of looking at systems) - benefit of PSO to see not alone Future focus – on how and what PEER review like activities are appropriate and fall within PSES & then really how can we better leverage our participation within the PSO Vizient PSO Presentation │ February 2019│ Confidential Information

Leveraging PSO Participation
Networking and learning from other participants Huddles PSO Meetings Utilize data trends and analysis for improvement Education participation and utilization Best practice participation Toolkits Safety alerts We can do this by participating in Best Practice Discussions, toolkit development and/or sharing our the toolkits to the appropriate teams and providers And communicate any safety alerts and/or report to the PSO if have any safety concerns with something such as a piece of equipment to identify if others having the same issue and for follow up with vendor/manufacturer, etc Vizient PSO Presentation │ February 2019│ Confidential Information

Launching Safety Event Reporting at a Large Outpatient Medical Practice
Priya Khatri, MBA, MPH University of Texas Health Science Center Houston, TX

UT Physicians Large ambulatory care medical practice
Physicians are faculty from University of Texas Medical School Houston, TX Over 100 clinics across area 1,500 clinicians certified in more than 80 medical specialties and subspecialties

Background on Safety Event Reporting
Prior to March 2018, there had been no system-wide assessment of safety culture at UT Physicians Reporting patient safety events was paper based and inconsistently used with no tracking and trending of events and lessons learned Organization was not ready for safety event reporting Needed to create a sense of urgency Vizient PSO Presentation │ February 2019│ Confidential Information

Guiding Principles to create major change
1. Establishing a sense of urgency 2. Creating the guiding coalition 3. Developing a vision and strategy 4. Communicating the change vision 5. Empowering broad based action 6. Generating short-term wins 7. Consolidating gains and producing more change 8. Anchoring new approaches in culture Kotter, J. P. (2012). Leading change. Boston, Mass.: Harvard Business Review Press Vizient PSO Presentation │ February 2019│ Confidential Information

The Need for a Safety Event Reporting System
Studies find that there are 2-3 safety incidents for every 100 primary care visits, and diagnostic errors occur in about 1 out of every 20 outpatient visits. Examples of the type of safety events at UTP include: Delay in reporting critical test results Incorrect concentration of topical application Medication errors (wrong dose, wrong drug, omission) Patient falls Infection control, sterile technique

McGovern Medical School GME Committees statement
In the 2017 Common Program Requirements, the ACGME requires that trainees “know their responsibilities in reporting patient safety events at the clinical site, know how to report patient safety events, including near misses, at the clinical site, and be provided with summary information of their institution’s patient safety reports.” During our two Clinical Learning Environment Review (CLER) site visits, the lack of an event reporting system in the UT Physician clinics was cited as a deficiency

The Need in a Nutshell… UTP has no method for reporting, analyzing, and learning from safety events Not knowing about these events, or not sharing lessons learned across the practice, hinders our ability to learn from these events and develop ways to prevent similar events from harming more patients in the future

Benefits of Safety Event Reporting
Vizient’s Safety Intelligence will provide UTP’s clinical and nonclinical staff a safe environment to report events that compromise patient safety. Safe care is care that is free from accidental or preventable patient harm produced by any aspect of medical care, and it is obviously a top priority of everyone here at UTP. Safety Intelligence will allow us to enter and document events, identify common factors that lead to events, and differentiate system issues from individual issues, thereby facilitating organizational learning, process improvement, and safer care. It will meet ACGME requirements and help us train the doctors of the future to think critically about patient safety and understand the importance of reporting and investigating events. The reporting of events and subsequent learning will prevent serious safety events that could harm patients, taint UTP’s reputation, and lead to lawsuits. Joining Vizient’s patient safety organization (PSO) will provide UTP with an extra level of legal protection should events lead to legal action. PSO membership will further promote our efforts to learn from and prevent safety events as we learn the best practices of other member organizations.

Gaining Buy-In from Key Stakeholders
Ambulatory Care Council Nursing Leadership Council Practice Manager meeting Department Manager of Operations meeting Clinical Chairs meeting/UTP Board Administrative Council Safety Event Reporting Committee Outpatient Quality Council GME Committee We also conducted a Safety Culture Survey to build awareness of safety culture and understand our organization‘s current state.

Guiding Coalition To prepare for the launch of safety event reporting, a large inter- disciplinary group of individuals were invited to participated in a Safety Event Reporting Committee (SERC) SERC Members included the vice dean for quality, RN leaders, practice managers, infection preventions SMEs, a physician champion, and more A Patient Safety Leadership Committee (PSLC) leads SERC and is now responsible for reviewing safety events and sharing lessons learned and best practices Vizient PSO Presentation │ February 2019│ Confidential Information

SERC Charter Overview /Problem Statement
Last updated 8/5/2016 SERC Charter Overview /Problem Statement Currently, UTP does not have a formal, well accepted way to report and track safety events. Without a safety event reporting program, UT cannot identify common problem areas or improve processes to prevent reoccurrence across the system. Employees may be reluctant to disclose an event when there is no formal mechanism or procedure to manage such events. Purpose To implement safety event reporting system in UTP and train and educate clinical staff in order to create a culture that supports reporting and learning from safety events Project Scope All UTP outpatient clinics, all patient interactions before, during, and after patient visit. Customer(s): Primary: Employees Secondary: Patients High Level Needs: Culture that encourages open discussion and learning from safety events IOM – Aim _X_ Safe ___ Effective _X_Patient Centered ___Timely ___Efficient _X_Equitable Aim Statement Short Term To install the Vizient Software on all UTP clinic computers by January 1, 2017 To increase awareness of new software program through training, education, and marketing (beginning fall 2016) Measure baseline safety culture with UTP wide survey (fall 2016) Long Term Identify improvement areas across clinics and encourage systematic PI (summer 2017) Assess change in safety culture with second UTP wide survey (fall 2017) Create a sustainable process/team of professionals to assess and follow up on safety events (fall 2017) Business Case UTP strives to provide safe care, and we are often unaware of events that compromise patient safety. Serious safety events can lead to patient harm, diminished quality of life, increased need for follow-up care, reduced employee morale, and patient satisfaction. SSE can expose UT to more legal risk.

Our plan was to divide and conquer by setting up committees
Leadership Engagement Technical Configuration and Installation Communication and Marketing Policies and Procedures PSES Management Education

Sub-Committees worked in parallel to prepare for the launch
Scope of Work Leadership Engagement Engage leadership. Ensure key stakeholders are informed on timeline and progress of installation and configuration and roll-out. Request feedback on processes and gain buy-in. Recruit physician leaders. Technical Configuration and Installation Work with Datix and UT Technical team to plan configuration and installation of software. Identify and engage stakeholders to ensure appropriate steps are taken to enhance security and workflow. Create workflow for QA and follow-up when issues arise. Communication and Marketing Identify and engage stakeholders early on and regularly. Create message to communicate benefits of safety event reporting. Present new program at relevant meetings, provide information in newsletters, and visit large clinics (if necessary) to publicize new program and gain buy in Policies and Procedures Create P&P related to "Stop the Line," event reporting, and follow-up processes related to event reporting. Distribute P&P and update as needed PSES Management Determine who follows up on reports and when. Design triage process for review and follow-up of events. Document resulting QI and learning resulting from events. Work with P&P group to develop sustainable and effective policy. Stay up-to-date with Vizient updates and community happenings. Education Create educational material for new hires and existing employees (clinical and non-clinical). Create and roll-out different modes of training (in person, video, LMS system). Vizient PSO Presentation │ February 2019│ Confidential Information

UT Physicians went live with Safety Event Reporting on March 1, 2018
Events Submitted since March 1, 2018 307 Patient Safety Events reported (as of 6/11/19) Events reported from 65 different clinics Vizient PSO Presentation │ February 2019│ Confidential Information

Current Event Review Process
Patient Safety Leadership Committee (PSLC) reviews event and routes event to clinic level leadership for review PSLC reviews event, asks follow-up questions if necessary, closes event, and submits to PSO Report submitted in Safety Event Reporting System Clinic leadership performs manager review Vizient PSO Presentation │ February 2019│ Confidential Information

Clinics and PSCL inspire process improvement
Patient Safety Leadership Committee (PSLC) reviews event and routes event to clinic level leadership for review (within one business day) PSLC reviews event, asks follow-up questions if necessary, closes event, and submits to PSO (weekly meetings) Report submitted in Safety Event Reporting System Clinic leadership performs manager review PSLC documents all interventions, shares lessons learned across practice, and facilitates further PI activity if necessary Clinic leadership may develop and implement intervention(s) to mitigate risk of event recurrence Vizient PSO Presentation │ February 2019│ Confidential Information

Our goal is to inspire long term improvement
Slide taken from 2nd module of NPSF Certified Professional in Patient Safety Curriculum (2016). Presented by: Dr. Doug Bonacum, VP: Quality Safety & Resource Mgmt, Kaiser Permanente. Vizient PSO Presentation │ February 2019│ Confidential Information

Reporting has resulted in many interventions that rely on education, but some interventions are work flow changes 307 events have led to 272 Interventions AND It is evident that event reporting has led to more conversations regarding safety Vizient PSO Presentation │ February 2019│ Confidential Information

More vaccine related events have been reported recently
Unclear whether incidence of vaccine related events has increased or reporting has increased Types of events reported (wrong dose, wrong vaccine, wrong diluent, administration of expired vaccines, etc.) Clinics have developed interventions to improve safety (new signs to clearly designate vaccinations, signs to remind staff which diluent to use, attached diluent to antigen, color code log books to help identify different types of vaccinations, etc.) Clinical educators will continue to educate existing staff and new hires in quality meetings, clinic in-services, and new hire orientation Safety Event Reporting Committee assembled a vaccination sub-committee Charter has developed and a cause and effect diagram has been created to identify factors that contribute to vaccine related events Vizient PSO Presentation │ February 2019│ Confidential Information

Interventions to help reduce error when preparing Shingrix vaccine
Vizient PSO Presentation │ February 2019│ Confidential Information

Manufacturer must’ve heard about issues and developed new and improved packaging!
Vizient PSO Presentation │ February 2019│ Confidential Information

Challenges  Successes
Challenge #1: Gaining Buy – In and Approval from senior leadership Waited for right timing Provided data to support need Compare cost/benefits of all options (buy system, build own, etc.) Challenge #2: Installation - New process, more technical than expected Recruited project manager from Clinical IT team to help manage the technical aspects of the project Challenge #3: Roll Out – Spreading the word Communication and Marketing Committee, Education Committee and recruitment of additional volunteers to visit clinics, create signs, brochures, and send s to publicize the new system and provide education on Safety Culture Vizient PSO Presentation │ February 2019│ Confidential Information

Challenges  Successes
Challenge # 4: Spreading Lessons Learned Difficult to inform > 100 clinics of all events and process improvements, we are actively working to create a sustainable process to follow-up on interventions and spread lessons learned Challenge # 5: Escalating concerns to correct leadership UT is a large practice characterized by an organizational structure with dotted lines across the medical school, ambulatory practice, and hospital. At times, it can be difficult to identify correct leaders and stakeholders. We are learning as we go and plan to be more proactive delineating appropriate leaders to engage in the future Vizient PSO Presentation │ February 2019│ Confidential Information

Ellen Flynn RN, MBA, JD AVP, Safety Program Vizient PSOE

Privileged and Confidential Documentation requirements
Peer review conducted within a provider’s PSES creates a “just” learning culture Event reported Report to PSO Peer review completed on event Deliberation and analysis (Provider and peer reviewers) (Peer reviewers) Provider closing conference Final peer review form completion PSES Privileged and Confidential Documentation requirements Date collected or created within PSES Date reported to the PSO Date removed (before reporting to PSO)* PSO submission: event report, peer review initial and final forms ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Documentation requirements
PSWP may be used within the provider organization and maintained within PSES Provider Not PSWP Event reports (factual medical record information) Medical records Provider PSES PSWP (additional facts, deliberation and analysis) Medical record abstraction form Deliberation and analysis Completed peer review forms PSO PSWP Feedback report Documentation requirements Removal from PSES must occur before PSO reporting Provider has responsibility to document date collected/created within PSES, removal or date reported to PSO ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Peer Review Activities conducted in a PSES are PSWP and the ability to disclose PSWP is limited Facility would have difficulty demonstrating that it had the required peer review process for example to CMS If peer review uncovers information that demonstrates the need to revoke or limit privileges, the PSWP cannot be used in court to support the facility’s decision, if challenged As a best practice do not conduct any peer review activity in a PSES that has potential to lead to an adverse employment action and meet any required peer review process outside of your PSES

CANDOR and PSOs: Improving patient safety
CANDOR: Build a just, culture of learning where honesty is normalize and patients family and caregivers are supported to achieve the best outcomes Encourage a team in your organization to become certified in CANDOR at the Vizient November 2019 education If not in a PSO, join one and consider Vizient: Establish a safe space to learn about why events occurred and how to prevent future events Leverage a PSO for insights and a forum to teach and learn ©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

Transform care with PSO participation
Organizations have flexibility when engaging with PSOs to contract for services Review and revise pertinent policies and procedures Identify PSWP use and communication with PSO and within provider Define and prioritize data collection, analysis and deliberation Define PSES workspace and equipment Identify staff that will support PSES activities Define goals for working with a PSO Evaluate impact of PSO Workforce Goals Workspace and equipment Data collection, analysis and deliberation Communication Revise policies Evaluate Vizient PSO Presentation │ February 2019 │ Confidential Information

Thank you! Questions?

Review PSES Consideration Checklist (1)
Workforce Develop grid with job titles, responsibilities and level of access to PSWP and purpose Identify 2 key contact roles for PSO Description of the following: PSES Workforce training plan Non-PSES workforce employees and providers training plan Who can enter event reports into the PSES Who can conduct additional investigations within PSES Who conducts proactive risk assessments within PSES Who collect any data outside of event reporting system or conducts deliberation, analysis and documents date Who reviews data after it enters PSES Who can remove data from PSES before reporting to PSO and record date Who can report to the PSO and record date reported Who can functionally report to PSO and record date Who has access to the functionally reported drive (PSO and internal) Who can conduct analyses/deliberations within PSES Who disseminates non-identifiable PSWP Who determines non-identifiable PSWP Who may disclose PSWP Vizient PSO Presentation │ December 2018│ Confidential Information

Equipment/software Patient safety software environment –define what is PSWP and what is not Secure functional reported drive within PSES and who has access Secure PSES drive and who has access PSES Operations Describe patient safety activities are conducted Describe how additional deliberation and analysis may occur within PSES Describe how a copy of other data may be reported to PSO Describe how data may be used internally Communication Describe how PSWP can be shared across health system and disclosed amongst affiliate providers if applicable Describe how PSWP is maintained within PSES Describe data collected (consider data inventory) Describe who can access PSWP for operation of PSES and/or interactions of PSES Vizient PSO Presentation │ December 2018│ Confidential Information

Disclosure Describe how, when and by whom PSWP may be disclosed, disclosure form used, and record retention (minimum 6 years for provider disclosure) Describe what and how PSWP may be disclosed amongst affiliate providers Functional reporting Describe agreement and how PSO has access Physical space (if any) Describe dedicated office space Describe any physical storage files Pertinent policies and other documents that might benefit from review Incident report Confidentiality Record retention Discipline Possibly peer review Training Manager investigation RCA Privacy and Security policy Risk Management Policies Vizient PSO Presentation │ December 2018│ Confidential Information

Speaker Bio In her role at Vizient, Flynn has oversight of the Vizient Patient Safety Organization (PSO), leading patient safety activities provided by the PSO to help members improve patient safety, health care quality and outcomes. She works with members on topics such as “Just Culture,” “High Reliability,” “Human Factors” and “Culture of Safety.” Prior to this position, Flynn had leadership responsibility for quality improvement, patient safety, regulatory compliance and patient engagement. In the past, she had responsibility for quality and accreditation services at University HealthSystem Consortium. She has extensive experience with both academic medical centers and large health systems, such as Children’s Hospital of Wisconsin, Rush System for Health, and Universal Health Services. Flynn developed one of the first PSOs in the country and has a keen understanding of how to help members operationalize their patient safety activities when working with a PSO. Ellen holds a bachelor of science in nursing from Loyola University Chicago, a master of business administration with a concentration in management information systems from DePaul University in Chicago, and a juris doctor degree from Loyola University Chicago. She is a certified professional in patient safety. Ellen M. Flynn RN, MBA, JD, Associate Vice President, Safety (312)

Speaker Bio Michael R. Callahan - michael.callahan@kattenlaw.com
Michael R. Callahan assists hospital, health system and medical staff clients on a variety of health care legal issues related to accountable care organizations (ACOs), patient safety organizations (PSOs), health care antitrust issues, Health Insurance Portability and Accountability Act (HIPAA) and regulatory compliance, accreditation matters, general corporate transactions, medical staff credentialing and hospital/medical staff relations. Michael's peers regard him as "one of the top guys […] for credentialing—he's got a wealth of experience" (Chambers USA). Additionally, his clients describe him as "always responsive and timely with assistance," and say he is "informed, professional and extremely helpful" and "would recommend him without reservation" (Chambers USA). Michael's clients also commend his versatility, and say "He is willing to put on the hat of an executive or entrepreneur while still giving legal advice," according to Chambers USA. He is a frequent speaker on topics including ACOs, health care reform, PSOs, health care liability and peer review matters. He has presented around the country before organizations such as the American Health Lawyers Association, the American Medical Association, the American Hospital Association, the American Bar Association, the American College of Healthcare Executives, the National Association Medical Staff Services, the National Association for Healthcare Quality and the American Society for Healthcare Risk Management. Michael was recently appointed as chair of the Medical Staff Credentialing and Peer Review Practice Group of the American Health Lawyers Association. He also was appointed as the public member representative on the board of directors of the National Association Medical Staff Services. He was an adjunct professor in DePaul University's Master of Laws in Health Law Program, where he taught a course on managed care. After law school, he served as a law clerk to Justice Daniel P. Ward of the Illinois Supreme Court.

Ellen Flynn RN, MBA, JD AVP, Safety Program Vizient PSOE

Similar presentations

Presentation on theme: "Ellen Flynn RN, MBA, JD AVP, Safety Program Vizient PSOE"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Ellen Flynn RN, MBA, JD AVP, Safety Program Vizient PSOE

Similar presentations

Presentation on theme: "Ellen Flynn RN, MBA, JD AVP, Safety Program Vizient PSOE"— Presentation transcript:

Similar presentations

About project

Feedback