NCQC Patient Safety. Organization. I ve Decided to be a NCQC PSO Member So Now What? Nancy Schanz, BSN, MA, MBA, MHA Kara Lyven, MBA.

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1 NCQC I ve Decided to be a NCQC PSO Member So Now What? Nancy Schanz, BSN, MA, MBA, MHA Kara Lyven, MBA

2 Objectives Maximize the protec/ons afforded under the Pa/ent Safety Act Outline specific steps and recommenda/ons for establishing a PSES and managing PSWP Understand how to opera/onalize par/cipa/on with and repor/ng to NCQC PSO 2

3 Polling Question I m overwhelmed at what I need to do now that I have become a member of the NCQC PSO. A. Yes B. No C. Somewhat

4 Is This How You Really Feel? 4

5 Report Events Deﬁne PSES & PSWP Iden/fy & Train Workforce Join PSO You Can Make It Over the Hurdles! 5

6 I ve Decided to be a NCQC PSO Member So Now What? Where is your organiza/on on the To- Do list? Join NCQC PSO Iden%fy & Train Workforce Define PSES and PSWP Report to NCQC PSO Ac/vely Engage with NCQC PSO 6

7 Identify Workforce 1. Start with the liaisons with NCQC PSO Primary and secondary contacts 2. Iden/fy core workforce to handle PSWP Define role in handling events 3. Sign and keep confiden/ality agreements 7

8 Assign Accountability for Reporting to NCQC PSO Web Portal Submit Survey Monkey: Verge New User Details 8

9 Educate & Train Workforce Two Groups: 1. Core Workforce Core Workforce handles events and reports to PSO 2. Greater Workforce Greater Workforce engages in discussions and analysis of pa/ent safety events 9

Work Force Training NCQC PSO contacts Topics Core Work Force Greater Force Authorized hospital liaison(s) X X PSQIA protec/ons and benefits X X What is a PSES, PSWP, Common formats, etc?

10 Work Force Training NCQC PSO contacts Topics Core Work Force Greater Force Authorized hospital liaison(s) X X PSQIA protec/ons and benefits X X What is a PSES, PSWP, Common formats, etc? X X Crea/ng protec/ve spaces for honest discussions, analysis X X Confiden/ality, penal/es X X PSES & PSWP policies and procedures PSWP Management (entering, edi/ng, submifng events) Removing PSWP from the PSES Handling requests for PSWP (approved disclosures) X X X X X 10

11 I ve Decided to be a NCQC PSO Member So Now What? Where is your organiza/on on the To- Do list? Join NCQC PSO Iden/fy & Train Workforce Define PSES and PSWP Report to NCQC PSO Ac/vely Engage with NCQC PSO 11

12 Building a PSES is like Build-A-Bear 1. Consider the variety of Furry Friends 2. Grab an un- stuffed bear from the bin 3. Put stuffing (and a heart) in your bear 4. Fluff your stuffed animal 5. Choose clothing and accessories 6. Fill out bear's info on the computer 7. Purchase the bear 12

Build-A-PSES 1. Consider your Pa/ent Safety structure 2.

Iden/fy current repor/ng systems and informa/on flow for

13 Build-A-PSES 1. Consider your Pa/ent Safety structure 2. Grab a blank paper and post- it notes 3. Iden/fy current repor/ng systems and informa/on flow for pa/ent safety ac/vi/es and events 4. Develop flowchart of these processes 5. Iden/fy what is missing/needs to change 6. Develop new/amend applicable policies 7. Implement newly defined PSES 13

14 Does building a PSES mean creating a whole new structure? No! You can use your current structure as your PSES. 14

15 Start with Your Current Structure Think of where events, unsafe prac%ces and near misses might be discussed 15

16 Define Where Discussions Occur 16

17 Add Event Reporting Process 17

18 Add the NCQC PSO Web Portal 18

about PSWP should be announced as taking place under

19 Define the PSES Look at where pa/ent safety events are discussed and documented (PSWP) - Discussions about PSWP should be announced as taking place under PSES Include these commipees/ mee/ngs in your PSES policy 19

pa/ent incident reports, sen/nel events, near misses, unsafe condi/ons, RCA, OPPE,

20 Define PSWP within the PSES Documents and informa/on submiped to NCQC PSO Web Portal Por/ons of mee/ngs which reviewed a quality of care/peer review event Adverse Events, pa/ent incident reports, sen/nel events, near misses, unsafe condi/ons, RCA, OPPE, FPPE, etc. Por/ons of Commipee Reports/ Minutes relevant to a pa/ent safety or quality event 20

21 Do we need to label PSWP? Yes! Label all PSWP to authen/cate its privileged and confiden/al status Include the date the informa/on entered the PSES Pa$ent Safety Work Product Confiden$al & Privileged This informa$on cannot be disclosed unless authorized by 21

22 Can Action Plans be included in PSWP? No, NCQC PSO does not recommend including Ac/on Plans in the defini/on of PSWP and does not encourage submifng them to the PSO. Why shouldn t I submit my ac%on plan to NCQC PSO? Including Ac/on Plans in the protected documents submiped to the PSO precludes it from being disclosed (for example to Regulators to demonstrate ac$ons taken to assure regulatory compliance and/or pa$ent safety) What if my RCA form includes an ac%on plan? Root Cause Analysis or other event inves/ga/on should be submiped with the ac/on plan redacted. 22

23 Can discussions involving individual performance be protected as PSWP? No. PSWP can NOT be used in disciplinary ac/ons such as Human Resource decisions or to support suspension of privileges. 23

24 Document Your PSES & PSWP in Policy Define PSES and PSWP in policy and include: 1. Where & how data/informa/on in PSES will be maintained 2. List of personnel involved in PSES Job /tles only Include their PSWP responsibili/es 3. How PSES func/ons Contact NCQC PSO for a policy template you can customize and/or use to add language to exis/ng policy 24

25 We are part of a system. Can we define a multi-hospital PSES? Yes! For a mul/- provider en/ty, the final rule permits either the establishment of a single PSES or permits the sharing of pa/ent safety work product as a pa/ent safety ac/vity among affiliated providers. 25

26 I ve Decided to be a NCQC PSO Member So Now What? Where is your organiza/on on the To- Do list? Join NCQC PSO Iden/fy & Train Workforce Define PSES and PSWP Report to NCQC PSO Ac/vely Engage with NCQC PSO 26

You may begin submifng data to the NCQC PSO as soon as you begin

27 Does the PSES policy have to be complete and final before we begin submitting data? No! You may begin submifng data to the NCQC PSO as soon as you begin the process of defining your PSES. Do not let the policy approval process slow down your ability to submit events 27

28 Identify Process for Submitting Events & Documents into NCQC PSO Web Portal Determine repor/ng mechanism Manual data entry vs. electronic data transfer Iden/fy what will be reported & protected All vs. sub- set of events Define /meframe for repor/ng NCQC PSO Web Portal 28

29 Complete Department Worksheet List names of all pa/ent care departments Map your hospital department names to a compara/ve group Submit to NCQC PSO 29

30 Learn to Use the NCQC Web Portal Prac/ce in the Training site hpps://vs1.verge- solu/ons.com/vstandard/default.aspx Username: NCQCTraining3 Password: Vergetraining! Review data entry webinar recordings 30

31 Submit to NCQC PSO 31

32 I ve Decided to be a NCQC PSO Member So Now What? Where is your organiza/on on the To- Do list? Join NCQC PSO Iden/fy & Train Workforce Define PSES and PSWP Report to NCQC PSO Ac%vely Engage with NCQC PSO 32

33 Actively Engage with NCQC PSO 1. Read monthly newslepers 2. Register for monthly webinars 3. Apend Safe Tables & Educa/onal Programs 4. Submit data in /mely manner 5. Provide feedback to NCQC PSO 6. Think outside the box! 33

34 Upcoming Educational Program The Human Factors Toolkit: Improving Order Sets and Alarm Safety When: October 6, :00 am - 4:30 pm Where: Cary, NC 34

35 Upcoming NCQC PSO Webinars Procedure Gone Wrong - Make it Right! When: October 15, 2015 from 11 AM 12 pm The Physician s Role in Pa%ent Safety When: November 17, 2015 from 11:00 am - 12:00 pm 35

36 Questions? 36

37 Thank You! Any further ques/ons, contact us! Nancy Schanz, RN, MA, MHA MBA, Director, NCQC PSO (919) Kara Lyven, MBA, Performance Improvement Specialist (919)

Exploi'ng the full poten'al of TCAS II. Capt. Pascal Kremer ERA / Luxair

Exploi'ng the full poten'al of TCAS II Capt. Pascal Kremer ERA / Luxair Content of this briefing Objec@ve and scope of the study Stakeholders TCAS reports Hot spots Findings and recommenda@ons Ac@ons taken