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/policies/administrative/uw-health-administrative/administration/162.policy

20170259

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UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Administration

Patient Safety Evaluation System (1.62)

Patient Safety Evaluation System (1.62) - Policies, Administrative, UW Health Administrative, Administration

1.62

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: Patient Safety Evaluation System
Policy Number: 1.62
Effective Date: March 1, 2017
Chapter: Administration
Version: Original
I. PURPOSE
To document a Patient Safety Evaluation System ("PSES") which creates a protected environment for
faculty, staff, and designated third parties to discuss and engage in quality and patient safety initiatives.
II. DEFINITIONS
A. Patient Safety and Quality Improvement Act. The Patient Safety and Quality Improvement
Act of 2005 and its interpreting regulation, the Patient Safety and Quality Improvement Rule,
(collectively, the " Patient Safety Act") authorized the creation of a national program through
which health care providers may voluntarily report quality and patient safety information on a
confidential and privileged basis to a Patient Safety Organization ("PSO").
B. Wisconsin Peer Review Statutes. The Wisconsin Peer Review Statutes, Wis. Code §§ 146.37
and 146.38, provide immunity to those participating in Patient Safety Activities and protects
Patient Safety Work Product from discovery or disclosure. Nothing in this policy is intended to
limit the scope of the protections afforded under the Wisconsin Peer Review Statutes.
C. Patient Safety Net. Patient Safety Net (PSN) is a real-time, online data collection and reporting
tool used within UW Health to capture safety incidents that occur throughout the organization. It
can be accessed by any employee of the organization as is used to trend and track safety
incidents.
D. Patient Safety Organization. A PSO collects, aggregates, and analyzes information to help UW
Health understand trends and offer strategies for improving patient safety and health care quality.
The Patient Safety Act encourages faculty and staff to share sensitive information and offers
broad protections so that participants can share information without the fear of discovery or
liability. UW Health participates in Vizient PSO.
E. Patient Safety Work Product. Patient Safety Work Product (“PSWP”) is any information
created or collected by any faculty, staff, or designated third party which could improve patient
safety, health care quality or health care outcomes that is assembled or developed in the UW
Health PSES.
F. UW Health PSES. The UW Health PSES consists of all Patient Safety Activities, including
individuals participating therein, and all committees and processes established for, among other
things, furthering patient safety or health care quality. The following list of committees is not
exhaustive but identifies committees specifically falling into the UW Health PSES:
1. UW Health Authority Board (UWHCA Board)
2. UWMF Board

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3. UW Health Patient Safety Committee
4. UWHCA Patient Safety and Quality Committee
5. RCA Subcommittee
6. Pharmacy and Therapeutics Committee and subcommittees
7. Infection Control Committee
8. Environment of Care Safety Committee
9. Departmental Peer Review Committees
10. UW Health Medical Board
11. Healthcare Associated Conditions (HAC) Leadership Committee
12. Pediatric Resuscitation Review Committee
13. Rapid Response Team Committee
14. Critical Care Committee
15. American Family Children’s Hospital (AFCH) Quality Coordinating Council
16. AFCH Joint Clinical Practice Council
17. Pediatric Medication Safety Advisory Group
18. Solutions for Patient Safety Adverse Drug Event Group
19. Solutions for Patient Safety Steering Committee
20. Clinical Labs Safety Committee
21. Sedation Steering Committee
22. Critical Care Transport Committee
23. Nursing Quality and Standardization
24. Nursing Education Council
25. Nursing Research Council
26. Nursing Coordinating Council
27. Nursing Staffing Council
28. Nursing Practice Council
29. Nursing Products and Technology Council
30. Ambulatory Pharmacy Leadership Meeting
31. Pharmacist Peer Review Committee
32. Graduate Medical Education Committee
33. Resident Quality and Safety Committee
34. Operating Room Committee
35. Quality Improvement Steering Committee
36. Ethics Committee
37. Medical Staff Committee and subcommittees
38. Radiology Quality, Safety and Innovation Committee
39. Lab Quality Service Team and subcommittees
40. UW-Madison Safety Committees including Radiation Safety Committee and
subcommittees
41. UW Health at The American Center Leadership Committees
42. Healthcare Event Evaluation Teams
43. Serious Event Analysis Team
44. Healthcare Associated Infections and HAC working groups
45. Quality, Safety, and Innovation Safety Leadership Meetings
46. Quality, Safety, and Innovation Peer Review Meetings

G. Patient Safety Activities. Patient Safety Activities consist of all deliberations, analyses, reports,
and any correspondence pertaining to patient incidents including, but not limited to, informal and
formal discussions, meetings, conferences, departmental meetings, departmental case reviews,
peer review documents, departmental reports and action plans. The following list of activities is
not exhaustive but identifies some activities specifically constituting Patient Safety Activities:

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1. Safety incident reports, and activities derived therefrom, submitted through the incident
reporting system (PSN)
2. Safety and quality incident investigations
3. Proactive risk assessment activities, Failure Mode and Effect Analyses
4. Apparent Cause Analysis and Root Cause Analyses
5. Peer review
6. Unsolicited patient feedback management
7. Medical and legal liability reviews
8. Morbidity and mortality conferences
9. Safety huddles and debriefs
10. Graduate Medical Education Resident Patient Safety Orientation

III. PROCEDURE

A. UW Health collects quality/safety information through the UW Health PSES for the purpose of
sharing patient incidents and learning from a system of analysis without the fear of discovery,
liability, or harm to reputation.
B. Any individual or committee within the UW Health PSES may report PSWP on a confidential
and privileged basis to other individuals or committees within the UW Health PSES or to the
PSO.
C. All Patient Safety Activities and Patient Safety Work Product, including any information and
analysis provided by a PSO, are confidential and privileged under the Patient Safety Act and the
Wisconsin Peer Review Statutes, and not subject to disclosure unless expressly waived by the
UW Health Chief Legal Officer.
D. Faculty and staff should make every effort to ensure that all written PSWP is labeled “Privileged
and Confidential” and to the extent possible should include the following disclaimer in the footer
of the PSWP: “This document is created as part of UW Health’s PSES and should be treated as
privileged and confidential under state and federal law, including but not limited to 42 USC
11101, et al (“HCQIA”), 42 U.S.C. 299 et. seq. (“PSQIA”), and Wi. Stat. §§ 146.37, 146.38,
905.03 and 905.04.”
E. The Vice President of Performance Excellence and Project Management serves as the primary
contact for Patient Safety Activities. Another designee of the Quality, Safety and Innovation
Department or the Risk Management Department may serve as an alternate contact.

IV. COORDINATION

Sr. Management Sponsor: SVP, Chief Nurse Executive
Author: VP, Performance Excellence and Project Management

Approval Committee: UW Health Administrative Policy and Procedure Committee

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer

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