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How Patient Safety Organizations (PSOs) can benefit patients and providers

On this episode, we take a closer look at Patient Safety Organizations, or PSOs. We look at their benefits for healthcare providers, the formation process and any compliance questions related to PSO formation.

Andrea Timashenka is PSO division director for the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality. Molly Huffman is a partner in Waller's healthcare compliance and operations group. And she has formed numerous component patient safety organizations for large healthcare entities and works with hospital association-based PSOs and various healthcare providers participant in commercial PSOs as well.


Morgan Ribeiro
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  • Transcript

    Morgan: Welcome to PointByPoint. This is Waller's Chief Business Development Officer and the host of the podcast, Morgan Ribeiro. On today's episode, I am joined by two healthcare leaders who are providing direction to hospitals and other providers in the formation of patient safety organizations, or PSOs, and compliance related to these PSOs.

    Andrea Timashenka is PSO division director for the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality. Molly Huffman is a partner in Waller's healthcare compliance and operations group. And she has formed numerous component patient safety organizations for large healthcare entities and works with hospital association-based PSOs and various healthcare providers participant in commercial PSOs as well.

    So welcome to the show.

    Andrea: Thank you. Pleasure to be here.

    Molly: Thank you.

    Morgan: Now, Andrea, I want to start with you - big picture. Can you share with our audience an overview of your role and the PSO division? And it might also be helpful just to talk big picture about PSO's in general.

    Andrea: Absolutely. So what the PSO division at AHRQ does primarily is implement the Patient Safety and Quality Improvement Act of 2005. What that really means - I tend to bucket it into three categories. So we conduct activities related to listing patient safety organizations that were established by the act. Then we also develop common formats, which are a method for providers to be able to collect information related to patient safety events and report that in a standardized manner to the patient safety organizations in a voluntary fashion. And then if the PSOs are so inclined, they can continue on and report that to us at AHRQ at a national level.

    And we have the kind of a third bucket of activities, which is maintaining a network of patient safety databases or the NPSD. And so we take some non-identifiable information that stems originally from the providers through the PSOs and can make it available at that national level for learning. So that's - in a very brief summary - sort of what the division does and how we implement the Patient Safety Act.

    We have responsibility for implementing most of the act at HHS. There is another office, the Office for Civil Rights, that has responsibilities related to implementing and to the interpretation related to the confidentiality provisions. I should mention that one of the key features of the Patient Safety Act is that it set up these federal protections, both privilege and confidentiality protections, for some of this information that is shared between the providers and the PSOs in order to encourage learning from these events.

    So that is the basics of the Act and also what we do with it. As far as some basic information about Patient Safety Organizations, we currently have 94 PSOs. It's the number we had at the end of 2020, and that's the highest number we've ever had at a year-end. So we're at a peak level. That's a basic overview of where we are right now.

    Morgan: So, what led to the passage of the Act in 2005?

    Andrea: It goes back to the IOM’s 1999 report "To Err Is Human." In that report, there are some specific recommendations to Congress to enact legislation along these lines - something similar to a state peer review protection at a national level. A lot of these problems are system errors and there was a lot of reticence among providers to share what's going on and what's happening because they were afraid of retribution in the form of medical malpractice and other litigation actions. Specifically recognizing that impediment to learning from patient safety events, unsafe conditions, near-misses, it doesn't have to be an event where harm occurred.

    Even in this general area, there was this lack of willingness for providers to talk amongst themselves and to get expert analysis and aggregation of their data. Congress considered multiple bills in that time that interceded from 1999 to 2005. And when this Act passed in 2005, it had wide bipartisan support and moved forward. So that's the history.

    Morgan: You've touched on this to some extent, but what do you find that hospitals and other providers value in being participants in a PSO?

    Andrea: There was a report from our HHS Office of the Inspector General's "Patient Safety Organizations: Hospital Participation, Value and Challenges" report. They talked to some hospitals and surveyed them and asked them questions about, what do they value and what does this mean for them?

    We've got some great information from that report, including that eight out of 10 hospitals find that PSOs have helped them prevent future safety events. One way that this is occurring is that the PSOs are able to aggregate rare events. So if you, as a hospital or health system maybe would only see, one event or not that many, you don't have the data to be able to see patterns and trends.

    If you're working with a PSO and when they work with some other providers and they have one or two examples of this as well. Now, if they can put together more of those examples, they can start to learn something that you wouldn't have been able to just from within your own facility or healthcare system, potentially.

    It also gives you the advantage of it doesn't have to happen to you first. If you're working with a PSO and something happened to the hospital that looks a lot like you down the street and then the PSO is able to help that provider work with what happened, there's potentially some learnings that you can get from that PSO and maybe that event never happens in the first place. So those are some of the reasons we think that it's helping hospitals and others prevent future safety events.

    Relatedly, another statistic finding we have out of that OIG report is that nearly two-thirds of hospitals found that working with the PSO resulted in measurable improvements in patient safety. Patient safety is a little notorious for being difficult to measure improvements but there are some hospitals that are finding ways to do the PSOs.

    Another advantage for the providers is that if they were trying to do these kinds of activities on their own - pulling frontline clinicians or others within their organization - if they engage with a PSO to have this expertise and do some of this analysis and aggregation for them. Then they can free up that frontline staff to do other activities, which, particularly in a timeframe like now when it's all hands on deck with COVID, can be extremely helpful.

    In addition to reporting information, just for providers to feel that if they're working with a PSO under the Act, they have a safe space, so to speak, to gather and exchange information about what's going on. Providers have given really strong feedback that just that ability to share that information and talk to their peers is really beneficial and that the PSOs have really benefited from that as well.

    For the providers to understand sort of the details of the protections that can be a real benefit for them. I alluded to state peer review privilege laws, which don't exist in every state.

    Some providers can't take advantage of them if they don't exist in their state. And being state laws, they vary state by state. So if you're a healthcare system that operates in more than one state, maybe what you can do in facility A isn't the same that would be protected in facility B across state lines.

    So under the federal protection, you've got this uniform blanket that you can use and do the same thing. State law protections are often also limited by exactly who and what are protected. Sometimes it's specific to hospitals and even not just hospitals, it has to be a particular committee that meets in a certain way and only that information can be protected. The information that can be protected under the Patient Safety Act is much broader than a lot of the state laws. And it's not restricted to just hospitals. So if you're not a hospital or if you're a large healthcare system that has hospitals and other types of providers, you could all be sharing information together under the protections in ways that typically you can't under most or at least some state laws that are somewhat similar.

    So that's a few of the benefits and then another one is submitting data to the network of patient safety databases and to be able to play a role in this national system of learning is something that is different and unique and valuable in participating with a PSO.

    Molly: Andrea, that was fantastic. And on the state piece, I think one of the areas that I have found most helpful for hospitals is this overlay blanket as you called it - protection and privilege. And going a step further with that, the state-based protections do end at the state borders or the state boundaries. So to give an example, I live in Virginia, which has an okay peer review statute, Kentucky and Florida are known in the country as having essentially none. They really have absolutely no protection. So to give you an illustrative example, if you have a hospital system that operates in Virginia and Kentucky, that protected information when it leaves the border of Virginia is not protected in any other state. And if you go to a state that really has no protection like Kentucky, there's nothing you can find to protect it.

    So in a pandemic, like COVID where we are all dealing with this same situation, the same pandemic certainly has played out differently in different parts of the country, but we're all dealing with the same virus and with a PSO overlay. To Andrea's point, you can share that information from Virginia to Kentucky, or even Virginia to California, and not worry that you have lost that state boundary.

    Many of our hospital clients really learn from that because what is happening in a hospital in California when surge rates were high might be very different than what's happening in say Virginia or West Virginia. Yet, before one of those other states had the high surge, they are able - if they're part of the same PSO or participating in a situation where they can share that PSO information, they're able to go ahead and learn and improve from it, which I just think is such an incredible advantage.

    Morgan: That's an interesting segway to my next question, which is, there's obviously been a lot of shifts in healthcare over the last 12 months. We've all been challenged. Andrea, is there anything in particular as it relates to PSOs, have you seen more interest? You said the number is higher than it's ever been. Do you see that interest still continuing to increase given what's going on in the world around us?

    Andrea: From what I hear from the PSOs, they're certainly busy working with their providers primarily on, or at least a lot on, issues related to COVID. It's obviously work they weren't doing at the beginning of 2020, whatsoever.

    And so a lot of them have shifted focus, but for the most part, what I hear is their preexisting ways of working with the providers - maybe with some tweaks here and there - are working. They have the systems in place and they're just applying it to different patient safety issues and continuing to go about their business of working with the providers.

    A lot of them are pretty nimble and able to shift focus, and they're used to shifting topics. They don't for focus on say falls for 10 years. Maybe focus on falls one year and you work on pressure ulcers the next year or something like that. So they're usually pretty good at adapting to what their providers need and the providers need a lot of support right now related to patient safety and COVID-19. We've heard some reports that reporting from the providers to the PSOs had lowered at different points, at least during COVID-19. However, I've also heard from some PSOs that when they took a look at that number, as it compared to the number of patient days, or, basically how busy they were, the numbers actually weren't dropping.

    They had a lower volume of procedures, et cetera, that they were performing at certain times and proportionally the number of patient safety-related reports they were getting have dropped. And a lot of that really depends on the type of PSO you are. If surgeries in your area were just canceled for two months, essentially, you probably didn't have any reporting. If you work with a provider who was just a general hospital who took COVID patients, maybe you shifted some of your activities, but your doors didn't close. It's a little bit of a mixed bag, but, in general, the PSOs are being really responsive to the needs of their providers. Maybe we've had to send out a few more reminders about deadlines, publicity and activities, but really happy that we haven't seen PSOs seeming to struggle to meet their typical requirements and really being engaged and active with the providers.

    I think there's that feeling of their services were already needed and it's now more than ever.

    Morgan: Okay. And Molly, what have you seen from hospitals and other providers during the pandemic in regard to PSO participation?

    Molly: Most of the areas that I've seen the biggest growth were in the learning opportunities. I've had a number of calls where folks have said, goodness, it's happening so fast. What do we do and how can we have these discussions? In some of these situations, they had not thought about the PSO because COVID had not been obviously thought about or put into the policies, but when we looked at what their committee structures were that were part of their PSES , those were perfect places to have some of these discussions.

    So I think more learning opportunities, evidence of more need for these safe spaces and really some creative thinking of using what was already there and growing it. On the reverse side, though, I will say I've had similar calls from providers who were not yet part of a PSO and we're dealing with COVID crises and when we talked about it and realized that participation with a PSO would be a perfect place for them. They had some homework and still have some homework to do. They sometimes are smaller providers that have not yet joined a PSO or what have you. So I will be surprised if there might not be an uptick from some of those situations, albiet COVID-based, that influx or increase some of those healthcare providers joining.

    One of the changes that I've seen providers perhaps need and being focused on are changes in their policies and procedures, the very essence of what creates their patient safety evaluation system, or PSES. I like to think of it as their safe space, where they are creating the work product, the boundaries and guardrails, and while the Patient Safety Act does not require all of that to be in formal policy, I have found that it's a best practice to do that because it gives them the guardrails. And I mentioned at the beginning of the call that often when they're challenged, it is in med-mal cases and I think that when you are challenged by somebody to say, wait a minute, what you were discussing or working on, wasn't actually Patient Safety Work Product if it is within your policy and clearly delineated, it's just a lot easier to make that argument.

    We've worked with a number of clients to clean up or shore up their policies, outlining their PSES after COVID, to give them some different, additional guardrails as a result of the COVID pandemic, whether that is perhaps contemplating Zoom or other electronic meetings for hospitals where they're discussing Patient Safety Work Product; many of those hospitals would never have done that.

    And often, quite frankly, in guidance from people like me and others who said if you can do this in person, obviously when you send something over email, you don't want to run the risk of it going to somebody's home email account or outside of the walls of that hospital. So ensuring that all of that is very protected and very confidential is important.

    But for all of us, how we work in COVID has changed. And so there are some of those meetings that have had to happen via Zoom or other secure mechanisms. And we have worked to both include those in the policies, but also to train folks on what that probably should look like and what extra precautions they can be taking wherever their remote location may be.

    Morgan: I'm going to switch gears here just a minute and talk about Common Formats. So for those who may not be aware, can you talk about what those are and the categories of Common Formats and how they have changed.

    Andrea: Absolutely. Common Formats are a set of standardized definitions and formats that make it possible for us to collect and aggregate and then analyze this uniformly structured information about patient safety at that local level and all the way up to the national level.

    The idea is we want to be able to conduct apples to apples comparisons of data. So if every hospital is working on the same patient safety issue, but collecting that in a different way, how are these PSOs going to be able to compare from hospital A to hospital B and how would we be able to figure that out on a national level?

    So the Patient Safety Act gave AHRQ the authority to create these Common Formats. So we have this common language to be able to talk about different patient safety concerns. We have two basic categories of Common Formats - Common Formats for event reporting and Common Formats for surveillance.

    So in Common Format for event reporting we have three setting-specific forms. We have a Common Format for the hospital setting, for the nursing home setting and for community pharmacy. And so within each of those settings, there are a set of these data descriptions for general patient safety concerns.

    You can report anything that you're concerned about and then we've also developed specific modules

    that are specific to each setting. I believe hospital has nine modules. There are less in the community pharmacies and nursing homes if I'm remembering correctly. - So that's how the event reporting Common Formats are set up and then we also have Common Formats for surveillance.

    Right now we have just one version - a hospital version, and this is still in beta. So it's not one of our full-blown versions yet, but we have this Common Format for surveillance as opposed to event reporting Common Formats.

    The idea is for it to be used in retrospective review of medical records. So you can go back and abstract and figure out whether certain patient safety events occurred. And like I said, we have a Common Format for surveillance for use in the hospitals. It powers a system that we use to help to calculate different rates, including national healthcare acquired conditions rates. And so we're working on that and the future of that. And then one thing that we're really excited that we're working on currently with Common Formats is a new Common Format in the event reporting realm specific to diagnostic safety. This is new and a little bit different and a change for a few different reasons.

    So one change is that this one's not setting-specific. We designed it to be used across all kinds of provider types. And we're hoping "different" in that when we were developing some of these other Common Formats for event reporting, there were already ways that hospitals and other providers were generally collecting this kind of information.

    And we see some issues with using common formats because a lot of folks already have a pre-existing system and there's definitely a cost and time associated with converting that to Common Formats. What we hear generally is that there's not really the same level of accepted measures for diagnostic safety.

    So we're hoping that we're a little bit more out in front with this one and that we can help the field,

    have this common language to be reporting on diagnostic safety concerns. So we're working really hard on that.

    We're hoping to make our draft available for public comment in a couple months. So that's our next step in the process with that one.

    Another change we made to at least the hospital Common Formats from some of the earlier versions is basically scaled it down. In our 2.0 version - in response to some of the comments we got that it was a barrier to using - because there was a lot of information being asked. However, I'll say that for the most part, what we see actually being reported to the NPSD is still in those earlier versions. So it's always trying to strike a balance between finding the right amount of information that there's enough there to get richnational learning, but at the same time, not be overburdensome to report. So we're always working on that and that's where we stand right now with our common format development.

    Morgan: What, if any, challenges are you seeing with the program?

    Andrea: Yeah, we do have our fair set of challenges. And this is also something touched upon in that OIG report I had mentioned earlier. There's a few that kind of overlap that the lack of familiarity still with the Patient Safety Act, even though that's been around since 2005, there's a lot of folks that still haven't heard about it.

    If you don't know a lot about the Patient Safety and Quality Improvement Act, a lot of times that can lead to redundancy. People think it's very similar to other activities they're doing and quality improvement and patient safety. And there is some uncertainty about the legal protections, as Molly alluded to a little bit, particularly in some states. Some of the case law that has come out regarding the Patient Safety Act has made some question a little bit how strong the protections might actually be. To address kind of that grouping of challenges, one thing that we're really working on is our education and outreach efforts.

    So we're trying to get the word out to more providers and others who would be interested in or working with PSOs and trying to show them how this is different from other activities they might be involved in.

    Again, this whole system is voluntary, so there's no requirement for them to do it. And as I just talked a little bit about Common Formats there, the PSOs - while we have them available for them - they're not required to use the Common Formats. They are required to collect information, and I'm paraphrasing and simplifying here, but in a standardized format across their providers, that can certainly include Common Formats, but there are other ways they could do that as well.

    So we're trying to do what we can to make it easier to for PSOs to report to the NPSD and for providers to be using the Common Formats to give the PSOs information in that way in the first place.

    One recent development in the NPSD. We used to have it set up that you basically could only submit data as a big batch, like once you had a lot of files or a lot of reports to submit over to this organization. We've created the PSO privacy protection center. So to make sure that information from the providers and PSOs meets the non-identification standard that's set forth in the Patient Safety Act and our implementing regulations.

    So that at the national level, none of the provider's information, nothing that would identify the providers, the reporters' information, or the patients would ever be available on that national level. And, like I was saying, it used to be that you had to submit data only, basically in these batch forms and it involved a certain amount of technical knowledge and skill.

    Recently, we've started to make available to the PSOs a system where they can log into that PSO PPC website. And fill out a web-based way to enter in reports. on like a one-by-one basis. Smaller PSOs or     those who might not have the IT infrastructure. We're trying to figure out ways to reach them and make it easier for them to report as well.

    And that's just one example. That's not going to solve everyone's problems in reporting to the NPSD, but we're trying to, within our means, figure out ways to make it easier to report.

    Morgan: Molly, anything you'd add to that. Because I'm curious in your work representing hospitals, are they typically coming to you and saying, "Hey, I'm interested in this whole PSO concept or is it they're presenting challenges to you and it's a recommendation to say, " You may want to look into this."

    Molly: So great question. I think both.

    In 2009, when the final regulations came out, a lot of large health systems were really interested in building their own PSO, their own component PSO, and that differentiation is one maybe I should highlight for the podcast. And that is that there really are three different kinds of PSOs.

    Component PSO is where you make a component of your own entity, if you will. So think large health system or midsize health system building their own and sharing within their own family. Those have been very popular for many of the reasons we've covered, including being across the country and sharing that information.

    A second type is what I call a trade association PSO. So think hospital association within a state offering it to all of their hospitals and the third kind, I call a commercial PSO.

    It is, by essence, a PSO that you would sign a contract with, pay money to, and join , and you would be sharing with lots of other entities like you and maybe unlike you as well.

    So I think that early on there was a lot of interest in maybe more of the component PSO, although it is grown rapidly across the country. To Andrea's point about Common Formats, many of the large hospital systems I have found like to use their own formats. Many of them had spent a lot of money and time and in technology to have formats and just chose to go that route, at least in their initial phase of operating within a PSO.

    I think with time, Common Formats have grown with favor and I would suspect they likely will continue to do. Also touching on your point, Morgan, about how people come to us. There are benefits to folks in the insurance world and otherwise to participating with the PSO and so many first took a look at it for those reasons.

    But I do think further education is so very important as Andrea likewise touched on because I think that without that continued education, whether it's with our own PSOs that are already up and operating or with those interested in either joining a PSO or creating their own is so important. Because if folks don't understand this, we do end up with bad case law. We do end up with people not using it, and then not being able to get the benefits of that protection, confidentiality and privilege. And that's not just for the healthcare providers. I have found that's for defense counsel. It is for the judges in the states. It is for all of the advisors helping those hospitals or physician practices or ASCs or fill-in-the-blank type of provider that is part of a PSO. It is a tremendous Act, but without really understanding the complications and nuances of it, I think that there are so many opportunities to forgo that protection. So that's an area that we really have spent some time working on with providers and even for those that have been up and running since the very passage of the Act and the final regulations, saying, "Okay, is it time to revisit this, is it time to retrain. For newer PSOs working with them on HR handbooks."

    Like, for example, If folks within your hospital overturn in positions, whether that's quality or risk management or some of those roles, is the PSO training part of onboarding at the very time of hire? And then do you have, whether yearly or " fill-in-the-blank" timeframe, of time to reeducate all of those individuals so that they really understand this.

    And then if there are changes in Common Formats, for example, if the hospital's using Common Formats, like Andrea mentioned, when those Common Formats change are, we seamlessly incorporating that into our software. And are we then re-educating the individuals who would be most responsible for that reporting platform.

    Morgan: You just mentioned a number of these things, but any other learning points or key takeaways that you wish those forming PSOs knew or were more aware of as they prepare to file for PSO certification this year or beyond. And this is really a question for you, Molly or Andrea?

    Molly: I'll try putting the brakes on. If folks are looking to create a PSO, there are so many learning opportunities as we've reiterated in this podcast because of COVID. But I think really hitting the brakes long enough to look at both how the world has changed and ensuring you are really crossing your T's and dotting your I's to ensure you've looked at your electronic platform, to make sure you have thought about how COVID has changed things, to make sure you've written your policies accurately. And really this is just from my perspective, that ensuring you are advising your clients that if they were to get audited tomorrow by AHRQ or HHS or any other entity, are they able with full confidence to say they have that background done both in paper, but also in practice.

    And that will serve them, I think not only in their PSO stead, but back to that medical malpractice, defense lawsuit example, when a defense attorney is knocking on their door and saying, "Hey, they want your PSO information."

    That it's not a situation where we just say "They can't have it," but we are really able to show. Nope. We built this protection. We walk the walk, and talk the talk, if you will.

    And so those are the kinds of conversations in the last six to nine months that I feel like I've been having a lot with clients and I'd be really interested in Andrea's take from the AHRQ side.

    But from my side, those are the sort of slow down conversations that I've been having a lot of both as a result of the pandemic and coupled with some of the case law we've seen across the country and heading into 2021 and the years thereafter to ensure we continue to have the benefits of PSO law without damaging it or watering it down.

    Andrea: Yeah. I'd love to build on a couple of those points that Molly said. She was talking about taking a step, a beat before someone goes to listing. One thing in particular I see sometimes, including our current environment, is for an entity that already exists and is already doing work in the patient safety and quality realm and is thinking about becoming a PSO.

    It's a little bit different calculation and a different level of thinking than some new entity that's coming into being, for example, as the example has been given as if you are a health system and you didn't have a PSO and you're going to form a component out of nothing. Certainly there's things you need to think about there and setting something up from scratch, but also for those who already exist in some form, and once you become a PSO or take part of their business and make it a component PSO to really understand what that means for your entity and to look through the requirements for that entity to be a PSO. Maybe our education efforts are starting to work and you understand more about the protections and you're like "yeah, that sounds great, I want that part of it." But there's other things that you're required to do as a PSO, and back to some of the case law, an entity who already existed and used to do things outside of the protections and now wants to do some of those same activities within the Patient Safety Act protections to be incredibly careful in dotting your I's and crossing your T's and setting that up because otherwise a judge might look at it and say, "Oh no, this isn't Patient Safety Work Product. This isn't the protected information. You were doing this before the Act or outside of the Act’s guidelines, et cetera."

    Sometimes, we really love the enthusiasm to become a PSO or to work with a PSO, but to understand how those requirements might impact an existing PSO or, sorry, an existing entity. We really encourage folks to get legal counsel to help them walk through that situation.

    Another thing that comes up from time to time - the Patient Safety Act and even our regulations - tedious as folks might find them to be - there is a lot of flexibility built into them, which normally you think, oh, people would think this is great. “I've got a lot of different ways that I can show I meet requirements such-and-such” but sometimes we find, a PSO just wants the answer. They just come to us and they're like, "What's the way to do this," and I usually don't have an answer to that kind of question. It's designed to be flexible. Congress realized that they wanted PSOs to look and feel different because they would be working with different providers and different kinds of providers and didn't want to put onerous requirements that wouldn't make sense for certain groups. So there's a lot of flexibility.

    Sometimes we do get the kind of, " Can you just tell me what language to plop in here to meet your requirement?" And so we try to help folks and, give them examples or walk them through potentially some of the issues they may encounter through technical assistance, but I don't often have the here just plunk this in kind of thing. And that actually frustrates some people sometimes that we are so flexible, but that's just the system that we are given.

    Once you're a PSO and we accept your certifications at AHRQ, you're listed for three years. And so every three years, you've got to go through a process to maintain that listing.

    The requirements are set up so that in that first three years, and once you become listed as a PSO, you say you're going to have policies and procedures to do a whole bunch of activities and meet certain criteria. So back to what Molly was saying about setting up that documentation and then, and so you've got that piece of it, but then you do have to walk the walk, as she said, and the attestations for your continuing listing period changes to that you have done the required activities and you will continue to do them.

    So you are given by the Act, this three-year set- up time, so to speak, to get all the wheels turning. But once you hit the end of that first three-years, the law expects that you have done all the patient safety activities.

    I encourage PSOs -and we try to help PSOs about six months before that listing deadline comes up- to look at all the requirements and make sure that they're meeting them. And then they have a little bit of time if they see something that they need to just shore up before the listing period ends.

    But, in particular, these eight patient safety activities that need to be met by the time that you've been listed for the first three years. And to make sure that a PSO is doing all of those. Sometimes a PSO might run away and be doing justGreat job, over and above on a couple of the activities, but maybe didn't see that there's a few others that they're required to do, too.

    So just to make sure that they know that they're required to do all of them during that three-year period of time.

    Morgan: Each of you sits in your respective seats and work with PSOs in different ways. How can they work more seamlessly with AHRQ and the certification process and compliance going forward?

    Molly, I'll start with you.

    Molly: I think getting a standard checklist. AHRQ has some great tools on their website, but I know for many clients I've developed a tweaked one for them after their initial certification that they can then re-use for each of those three-year re-certifications, and also they dusted off towards that recertification call that Andrea mentioned that's usually six months before. So maybe nine months before recertification to dust that off and to say what worked last time that maybe could be improved this time or how have we grown and changed? I think that can be a helpful tool too, and really just keeping an eye on what has happened for that entity’s, own lawsuits in that state.

    And if they operate in a state that has had bad PSO law, even if it was not their own, what happened there and can they advise their defense counsel? For example, one other thing that we will do is say to a PSO, we will train all of your defense counsel. Let's say they have malpractice defense counsel in 30 states, for example, and maybe state court judges are looking at this differently in many of those states that we can say for that hospital or healthcare system: " Here's our training on this. Here's how we would recommend you approach it and then help them, too, with those briefs, affidavits and other supporting work.

    So that we are getting both the same message out for that particular PSO in a uniform manner, but also very much trying to strengthen the case law across the country.

    Andrea: Yeah. And I would add a few things. For one, just for the PSOs to know that AHRQ is available for technical assistance anytime.

    We can do that via email and we can set up calls if the email won't suffice. There's particular areas that I see time and time again that a quick call or an email can save a PSO a lot of time and worry particularly around, for example, the disclosure statement requirements.

    A lot of times once a PSO talks to us, they realize the requirement doesn't apply to them. And that's a lot less work than if it does require them to submit a statement. So hopefully the PSOs feel free to reach out to us and we can guide them through the processes. Otherwise, for PSOs to work more seamlessly, I think we've done at AHRQ a pretty good job of communicating with them about the certification and compliance, but we still have room for improvement and there's some areas we've been working on there.

    So, for example, within a PSO’s authorized official login part of the website, we've been updating a timeline in there that gives you a more personalized showing of when upcoming listing deadlines are due.

    And also hopefully some more information about the past submissions that you've had accepted as well. So trying to make that easier since there are some different dates that happen throughout the year. As far as compliance goes, we are working on trying to update our compliance self-assessment guide and hope to have that resource out before the end of the year.

    And just overall a little bit better, should you be a PSO that's chosen for a compliance assessment, I think we can do a little bit better job on our communication of what we're really asking for, what we're really trying to double check your compliance with and just get everyone on the same page.

    We encourage the PSOs to reach out for us and for technical assistance and around those required processes, we're trying to include trying to improve the communication from our end as well.

    Morgan: This has been really informative. I know for myself, I don't live and breathe PSOs every day, and I hope that our listeners who are not living in this world every day find that this is informative information. And thank you again.

    Molly: Thank you, Morgan.

    Thanks, Andrea.

    Andrea: Thank you, Morgan.

    Thank you, Molly. I really appreciate the opportunity.

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