PSOs: The Power of Aggregation of Data

Patient Safety Quality Monthly

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November 14, 2008

Recent changes in the laws at the federal level have established the ability to submit your occurrence report data, cause analysis data and peer review data to a Patient Safety Organization (PSO). The new law provides for two key areas:

• Stronger confidentiality and protections that may be more attractive than the present state laws (especially in some states)
• The ability of the PSO to share aggregated, de-identified information back to all of the members of the PSO.

Aggregation means "combining together". When we talk about aggregation of data we are talking about collecting more data so we can combine the data together and get a clearer picture of what is happening.

Let's look at three different levels of aggregation and how that impacts our ability to improve rapidly.

1. No aggregation. We do a root cause analysis and look just at that one analysis. This really is the least effective place for us to be. All we know about is that one event. It really doesn't fit into context, and we can end up making very expensive changes based on limited data. We paid the price of a very serious event to perhaps learn 3-4 useful pieces of information. That is an extremely high cost of learning.
2. Limited aggregation. We look at 5 RCAs that we did this year in an aggregated fashion. This is starting to increase our understanding of our facility rapidly. Think of the power if you could go back to your leadership and say, "Thirty-two percent of the worst things that happened to us this year were caused by poor communications." This gets much faster buy-in and there is less chance we will spend our limited resources in the wrong place.
3. Wide-scale aggregation. You submit your RCAs to a Patient Safety Organization (PSO) and get the results of the leading causes of harm or no-pay events across all the members. Now we are really moving to reduce our "cost of learning". Now your facility has access to the learning of all the members and you do not have to pay the price of a harm event, no-pay event, or a serious regulatory violation. You learn from the problems of others without having to pay the price at your facility. Those who do this and pay attention to the learning of others will excel in our very competitive markets.

Effective use of aggregated data can reduce our cost of learning from hundreds of thousands of dollars per "learned nugget" to just thousands of dollars. Not only is this a significant financial benefit, it speeds up our rate of improvement and makes our facilities safer that much faster.

Ken Rohde

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