NAPA earns AHRQ Patient Safety Organization listing, becoming one of only 89 PSOs in the U.S. creating a culture of safety for healthcare providers
By Julie Marhalik-Helms, BSN, RN, Vice President of Quality Improvement, NAPA
The NAPA Anesthesia Patient Safety Institute has become one of only 93 Patient Safety Organizations (PSOs) in the country, following approval granted by the Agency for Healthcare Research and Quality (AHRQ), an agency of the U.S. Department of Health and Human Services (HHS), on December 10, 2019.
Establishing our own federally listed PSO is a giant step forward on the path to creating a uniform culture of safety across NAPA’s entire geographic footprint. Because NAPA is a PSO, its clinicians in any state can now discuss cases without fear of punitive repercussions. PSO status facilitates—and, in fact, encourages—open discussion among NAPA clinicians and our hospital partners about adverse events, root cause analyses, and action plans, in pursuit of achieving better outcomes.
PSOs were mandated by the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) to “improve quality and safety by reducing the incidence of events that adversely affect patients.”1 In proposing the act, legislators acknowledged that to reduce adverse events and hospital readmissions, healthcare providers needed a protective environment that would allow for the free exchange of information. To this end, conversations and activities under the PSO are legally protected (not discoverable), so that providers can review adverse cases with colleagues to prevent reoccurrence and ultimately deliver safer patient care.
NAPA has long recognized the value that a PSO bestows to providers, partners, and patients. As a founding member of the Anesthesia Business Group (ABG) in 2009, NAPA was one of the first anesthesia services companies to help establish that entity as a PSO and conduct the quality and safety-focused work that drives a patient-first organization. Now, as NAPA has grown and developed its infrastructure, our belief in the powerful impact that a PSO has on patient care and clinician wellness inspired the evolution of the NAPA Anesthesia Patient Safety Institute. With our own PSO, we can develop new initiatives, maximize data, and allocate more resources to case reviews and caring for our clinical caregivers.
To earn the prestigious PSO listing, an entity must establish its expertise and be dedicated to improving patient safety and healthcare quality. As a designated PSO, the NAPA Anesthesia Patient Safety Institute is required to work on behalf of the healthcare providers it serves to conduct eight “patient safety activities” including:
- Efforts to improve patient safety and the quality of healthcare delivery
- The collection and analysis of patient safety work product (PSWP)
- The development and dissemination of information regarding patient safety, such as recommendations, protocols, or information regarding best practices
- The utilization of PSWP for the purposes of encouraging a culture of safety as well as providing 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 patient safety evaluation system and to the provision of feedback to participants in a patient safety evaluation system1
NAPA already collects clinical quality information under our patient safety evaluation system (PSES) for every one of the 1.2 million patients per year for whom we provide an anesthetic. We regularly analyze this data and discuss outcomes, trends, standard of care, processes, protocols, and best practices at monthly regional quality meetings and at an annual meeting of our quality leaders. Data reviews and case evaluations at these meetings are protected under our PSO, and they generate PSWP that we then disseminate to clinicians throughout NAPA so that all may benefit from our analysis and collective problem solving.
AHRQ also promotes the public sharing of clinical education that results from PSO activities to advance healthcare quality nationwide. For example, NAPA was honored to present a study about sedation-related adverse events in endoscopic procedures at the 2019 annual meeting of the Society for Ambulatory Anesthesia (SAMBA).
Data is critical to quality improvement, and NAPA continues to be an innovative leader in how data is collected and applied. Enhancing how we use data to learn from adverse events, we are proud to announce that the first initiative to launch under our new PSO is the NAPA Quality Improvement Patient Safety (NQIPS) tracking system. After nearly nine months in development, this new technology will electronically determine which adverse events require a case review by clinical experts, enabling us to better address preventable complications that may compromise patients and cause clinician distress.
Additionally, we are furthering our safety culture with two new initiatives designed to help “second victims” in adverse events and support our clinicians’ physical and mental health. Please watch for more information about these two important programs coming soon.
NAPA’s investment in creating a PSO signifies our dedication to being the anesthesia destination of choice. For anesthesia clinicians, this means working confidently in a culture of safety and collaboration, in an environment where everyone understands that if we expect our clinicians to deliver the best care for our patients, we must do everything we can to take care of our clinicians.