Patient Safety Organizations: Improving Quality and Safety Nationwide

Within the protected environment that affords privilege and confidentiality safeguards, the four PSOs described here have used AHRQ tools to expand their quality and safety improvement programs to nearly every State in the Nation. Being able to freely share best practices and lessons learned among partner facilities has resulted in reductions of harms, including falls, infections, and vascular events that can cause significant morbidity and mortality in health care settings.

EQUADR: Carolinas Rehab PSO LogoCarolinas Rehabilitation PSO

  • Created the EQUADRSM network for QI in inpatient rehabilitation facilities.
  • Members share quarterly data on quality measures, best practices, and challenges.
  • PSO attributes include protected, safe, and non-punitive environment to share Chart shows a 70% decrease in Catheter-associated Urinary Tract Infections from 2010 to 2015.
    safety data.
  • There was a steady decline from 2010 to 2015 in the following quality indicators:
    • Unassisted falls, 18.6% decline.
    • Restraint use, 40.6% decline.
    • Pressure ulcers, 30.9% decline.
    • Venous thromboembolism, 25.9% decline.
    • MRSA, 68.3% decline.
  • Benchmarks provide context for strengths, weaknesses, and relative rate of improvement.

Learn more about the impact of AHRQ tools in this facility.

 

This image summarizes the work of the Carolinas Rehabiliation PSO: created the EQUADRSM network for QI in inpatient rehabilitation facilities; members share quarterly data on quality measures, best practices, and challenges; PSO attributes include protected, safe, and non-punitive environments to share safety data; EQUADR aggregate data show a steady decline in quality indicators: restraint use and unassisted falls rate, pressure ulcers, VTE, MRSA, and CAUTI and urinary catheter use; benchmarks provide context for strengths, weaknesses, and relative rate of improvement. A map of the United States highlights North Carolina, where the PSO is located, and the following States that have adopted the best practices of this PSO program: Alaska, Arkansas, California, Colorado, Florida, Georgia, Illinois, Indiana, Michigan, Minnesota, Mississippi, New York, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia. A bar graph of CAUTI indicates a 70% decrease in healthcare-associated infections (per 1,000 device days) from 2010 to 2015. The logo indicates the facility is listed as part of the PSO Program. Listed PSO Logo

 

ECRI Institute PSO LogoECRI Institute PSO

  • Christiana Care Health System piloted a Lean Six Sigma process to form an interdisciplinary team that would reduce the average patient falls rate below the national benchmark.
  • Unique, protected PSO environment facilitated trend analysis, root cause identification, and action plan development. Early and active engagement from leadership and frontline staff helped achieve:
    • A 52% reduction in the combined falls rate on the three pilot units, far exceeding their goal of a 30% reduction.
    • A reduction in the overall falls rate from 4.8 in 2012 to 1.80 in 2015 across three patient care units.
    • A reduction in the annual cost of falls by $20,000.
    • Statistically significant differences in success of strategies between units involved in the Lean Six Sigma strategies and those units not involved.
This image summarizes the work of the ECRI Institute PSO partnering with Christiana Care Health System: Christiana Care Health System piloted a Lean Six Sigma process to form an interdisciplinary team that would reduce the average patient falls rate below the national benchmark; unique, protected PSO environment facilitated trend analysis, root cause identification, and action plan development; early and active engagement from leadership and frontline staff helped achieve a greater-than-expected reduction (52% vs. 30%) in the falls rate and significant total cost reduction ($20,000); post piloting the study, ECRI Institute PSO has implemented the Falls Prevention tool in four other States. A map of the United States highlights Pennsylvania, where the PSO is located, and the following States that have adopted the Falls Prevention tool: California, Delaware, Michigan, and New Jersey. The logo indicates the facility is listed as part of the Patient Safety Organization Program. Listed PSO Logo

 

HCA PSO LogoHCA PSO

  • Recruited 152 hospitals facilities to participate in the Clinical Safety Improvement Program, with a goal of reducing hospital-acquired conditions or healthcare-associated infections by 10%.
  • All facilities met the target of reduction in at least one event category.
  • 85% of the facilities exceeded expectations by achieving reduction in 3 or more categories.
  • Staff freely shared lessons and best practices across member facilities in 20 States—attributable to the privilege and confidentiality protections unique to a PSO program--to improve quality and safety, and reduce harm.

Learn more about the impact of AHRQ tools in this facility.

This image summarizes the work of the HCA PSO, LLC: recruited 152 hospital facilities to participate in the Clinical Safety Improvement Program, with a goal of reducing hospital-acquired conditions or healthcare-associated infections by 10%; all facilities met the target of reduction in at least one event category; 85% of the facilities exceeded expectations by achieving reduction in 3 or more categories. Staff freely shared lessons and best practices across member facilities in 20 States—attributable to the privilege and confidentiality protections unique to a PSO program—to improve quality and safety, and reduce harm. A map of the United States highlights Tennessee, where the PSO is located, and the following States that have adopted the best practices of this program: Alaska, California, Colorado, Florida, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Nevada, New Hampshire, Oklahoma, South Carolina, Texas, Utah, and Virginia. The logo indicates the facility is listed as part of the Patient Safety Organization Program. Listed PSO Logo

 

Society for Vascular Surgery PSO LogoSociety for Vascular Surgery PSO

  • The Vascular Quality Initiative (VQI) showed improved survival among patients on antiplatelet and statin medications.
  • For every 25 patients discharged on an antiplatelet agent and a statin medication, an additional 3.5 were alive at 5 years.
  • VQI participation improves the use of medical management, demonstrating that organized quality efforts can affect patient outcomes; successes were subsequently expanded across 44 other States.
  • Sharing actions taken in a PSO protected learning group (based on challenging areas within the aggregate performance data) improves vascular care.
This image summarizes the work of the Society for Vascular Surgery PSO: the Vascular Quality Initiative (VQI) showed improved survival among patients on antiplatelet and statin medications, for every 25 patients discharged on an antiplatelet agent and a statin medication, an additional 3.5 were alive at 5 years, VQI participation improves the use of medical management, demonstrating that organized quality efforts can affect patient outcomes; successes were subsequently expanded across 44 other States, Sharing actions taken in a PSO protected learning group (based on challenging areas within the aggregate performance data) improves vascular care. A map of the United States highlights Illinois, where the PSO is located, and the following States that have adopted the VQI: Alabama, Alaska, Arkansas, Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin. A graph indicates Survival by Discharge Medications, with fewer patients surviving if not given AP or statin versus more patients surviving with AP and statin medication. The logo indicates the facility is listed as part of the Patient Safety Organization Program. Listed PSO Logo

 

Four Featured PSOs

This image summarizes the work of the four featured PSO programs: Carolinas Rehabilitation PSO. The PSO shared tools from AHRQ's Preventing Falls in Hospitals guide with its facilities. Specific sections that were considered to be helpful include universal fall precautions (including the scheduled rounding protocols); standardized assessment of fall risk factors; care planning and interventions addressing risk factors within the overall patient care plan; and post-fall procedures (including a clinical review  and root cause analysis); ECRI Institute PSO. Since 2008, ECRI Institute PSO, an AHRQ-certified Patient Safety Organization, has provided multiple resources, feedback, and tools to their members, which have helped Christiana Health System. By using the tools provided by our PSO, we were able to target opportunities for improvement, identify and remove barriers, said Ms. Mascioli, summarizing lessons learned to the other PSO member providers; HCA PSO, LLC. Dr. Jane Engelbreit, HCA PSO, LLC authorized official, attributes much of the success of the Clinical Safety Improvement Program and improvement efforts to the privilege and confidentiality protections uniquely afforded to a PSO. Within the PSQIA environment, staff could freely disseminate lessons learned and share best practices across all member facilities in 20 States, resulting in quality of care and patient safety improvement and harm reduction.

 

Page last reviewed October 2017
Page originally created July 2017
Internet Citation: Patient Safety Organizations: Improving Quality and Safety Nationwide. Content last reviewed October 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cpi/about/otherwebsites/pso.ahrq.gov/pso-benefits.html