CHPSO Patient Safety News

December 2012

In this issue:

  • New look reflects CHPSO's growth
  • The time is now for PSO participation
  • Free support offered to implement PSES and report data
  • Benefits of the QI Model for clinical peer review
  • Counsel discussion group forming
  • CHPSO launches new website
  • Sorrel King to speak at CHPSO Annual Meeting
  • Register now for CHPSO's 2013 Annual Meeting
  • Upcoming events

New look reflects CHPSO's growth

With this issue of Patient Safety News, CHPSO unveils a new logo—and a new look for the newsletter. Our new logo reflects CHPSO's growth and stability. It suggests a fluidity of process, collaboration and continuous improvement. The internal shape of the logo forms a circle or “zero,” symbolizing the shared quest to eliminate preventable harm completely.

Since its inception in 2008, CHPSO has grown to 271 member hospitals and is a trailblazer among patient safety organizations (PSOs), working with national manufacturers to improve safety of devices, leading a seven-state consortium to reduce retained surgical items, and serving as a leader in the Nationwide Alliance of Patient Safety Organizations. CHPSO’s Patient Safety Alerts have been distributed worldwide.

In February, CHPSO partnered with ECRI Institute to accelerate confidential data reporting and analysis, and expand member offerings. CHPSO now offers many complimentary services to help hospitals improve patient safety—support for connecting to CHPSO's data reporting system, root cause analysis critiques, custom research reports, sample policies and procedures, and access to ECRI Institute’s learning portal.

To learn more about CHPSO, visit

Time is now for PSO participation

Until recently, PSO participation, while the right thing to do, has not been mandated. That is changing for most hospitals. Congress recently added a very strong financial incentive for hospitals to join PSOs.

Affordable Care Act incentive

The Affordable Care Act of 2010 calls for states to create health insurance exchanges, which must be operational by Jan. 1, 2014. Health insurance exchanges are charged with expanding coverage for the uninsured, improving health care quality, reducing costs, and empowering consumers to choose a health plan that gives them the best value.

By Jan. 1, 2015, qualified health plans in insurance exchanges may not contract with a hospital of 50 beds or more unless that hospital has a Patient Safety Evaluation System in place that collects, manages and analyzes information for reporting to a PSO. Hospitals wanting to participate in this insurance market will need to comply with that requirement.

Deadline looming

Although Jan. 1, 2015 may seem a ways off, it is not. Contracts with health plans are typically for one-year terms or longer. This means that by Jan. 1, 2014, new contracts must comply with 2015 requirements or be terminated at year-end.

Free membership

CHPSO membership is a free benefit for members of CHA and California’s Regional Hospital Associations. Membership is also available for hospitals outside California for a fee. A contract is required and a copy is available at Direct questions to Rory Jaffe, at or (916) 552-7568.

Free support offered to implement PSES and report data

CHPSO and its partner, ECRI Institute, offer help with implementing a Patient Safety Evaluation System (PSES) and reporting data to CHPSO. Free support includes a hospital policy and procedure template that can be customized for individual hospitals. For those hospitals unable to use a prepackaged reporting solution, free consulting services (available for a limited time) provide turnkey solutions to electronic reporting. Both RL6 and MIDAS+ have prepackaged solutions for reporting, as may other vendors. Please contact your incident reporting system vendor for more information.

Members can learn more during two upcoming webinars, PSO Basics on Jan. 16, 2013, and Patient Safety Evaluation Systems on Feb. 13, 2013. See for details.

For more information about free support services contact or (916) 552-2600.

From QA to QI

Benefits of the QI Model for clinical peer review

Marc T. Edwards, MD, MBA

The Quality Assurance or QA Model for clinical peer review has far outlived its utility in meeting Joint Commission requirements. Now, it only serves to perpetuate a culture of blame and poison efforts to develop a culture of safety and high-reliability. Because peer review remains the dominant method by which adverse events are examined, the mode in which it is conducted has far-reaching effects. Progress in patient safety will be stymied until the model is changed.

My research has characterized a Quality Improvement or QI Model that corrects the dysfunction of the QA Model. (1,2,3,4) The QI Model is the result of consistent application of well-established quality improvement principles to the process of peer review. These principles hold that human error is inevitable. Error occurs most commonly as a result of multiple interacting factors in the system of care. Thus, the QI Model views all adverse events, near misses and hazardous conditions as organizational learning opportunities.

Read full article

Counsel discussion group forming

CHPSO is forming a discussion group to help attorneys address the new legal privileges and challenges of the Patient Safety and Quality Improvement Act of 2005. This act, which established patient safety organizations as well as a new legal privilege (Patient Safety Work Product), is starting to be tested in court.

As the Affordable Care Act will soon require that most hospitals of 50 beds or more participate in a PSO, more hospitals will need assistance with issues related to the Act and the new work product privilege. The discussion group is not restricted to CHPSO members, which now total 270 facilities. CHPSO plans to operate the group primarily via email and conference call as needed. To participate, sign up here. Extensive legal references, including the amicus curiae briefs in several recent significant cases, can be found on CHPSO’s website.

CHPSO launches new website

Be sure to visit CHPSO’s new website that supports our collaborative work in accelerating safety improvements and eliminating preventable harm. The new site improves usability, increases member interactivity, and delivers valuable content and resources. As always, CHPSO welcomes your input. Send feedback and/or suggestions to Frances Sutz Brown, director of Operations and Communications,

Sorrel King to speak at CHPSO Annual Meeting

Nationally renowned patient safety advocate Sorrel King will speak at CHPSO’s Second Annual Meeting—Getting to Zero: Innovate, Collaborate, Accelerate—April 8–9, 2013, at the Hyatt Regency Sacramento. In 2001, Sorrel King’s daughter Josie died as a result of medical errors. Consumed by grief, Sorrel was determined to honor Josie’s memory. She and her husband created the Josie King Foundation to prevent others from dying or being harmed by medical errors. The foundation has been a pioneer in uniting health care providers and consumers, and funding innovative safety programs.

Register now for CHPSO's 2013 Annual Meeting

Online registration is now available for CHPSO's Second Annual Meeting—Getting to Zero: Innovate, Collaborate, Accelerate—April 8–9, 2013, at the Hyatt Regency Sacramento. Register by March 7, 2013 and receive a discounted rate.

Member cost is $295 and non-member cost is $400. Fees increase $100 after March 7. For those who prefer registering by mail, CHPSO will send out program brochures with registration forms in early January.

The Annual Meeting provides innovative strategies and practical tools for participants to take back to their facilities. Topics include groundbreaking patient safety work, culture change, technology, medication and surgical safety, human reliability, the legal and regulatory horizon, and much more. The program is designed for hospital CEOS, senior leaders, and clinical leaders, including physicians, nurses, quality, risk and patient safety staff, and pharmacists.

The Hyatt Regency Sacramento is the host hotel for the meeting. A special room rate of $179 is available for single/double occupancy. Please call the hotel directly at (888) 421-1442 and mention the “CHPSO conference” to make your reservation at the discounted rate or click here to reserve your room online. Discount sleeping room deadline is March 18, 2013.

Upcoming events

California Hospital Patient Safety Organization

Unless noted, all events are for CHPSO members only. Members will receive an email a few days before each event with information on how to participate. All times are for the Pacific Time Zone. For more information, contact or call (916) 552-2600.
December 10 Monthly Member Call, cancelled due to conflict with the Institute for Healthcare Improvement (IHI) Annual Meeting.
December 20 CHPSO/ECRI Radiology Patient Safety Webinar, 8–9 a.m.
January 16 CHPSO/ECRI PSO Basics Webinar, 10–11 a.m.

Hospital Association of Southern California

January 23 HASC’s 5th Annual Patient Safety Colloquium, 7:30 a.m.–3:45 p.m., Hyatt Regency, Orange County.

Hospital Association of San Diego and Imperial Counties

December 5 Patient Safety First Luncheon and Education Program, 11:30 a.m.–3:30 p.m., Handlery Hotel, San Diego.

Copyright © 2012 CHPSO, all rights reserved.