Frequently Asked Qustions
  1. What is a PSO?
  2. What is the purpose of a PSO?
  3. What is patient safety work product (PSWP)?
  4. What documents might be considered PSWP?
  5. What documents would NOT be considered PSWP?
  6. What are patient safety activities?
  7. Do PSOs receive federal funding?
  8. Why are the terms safety and quality used together when describing the role of PSOs?
  9. What are the benefits to healthcare providers who work with a PSO?
  10. In some states, assisted living (AL) communities are not considered healthcare providers. Will these AL communities be protected under the Patient Safety Act?
  11. What data will be collected in the PSO?
  12. How will data be submitted in the PSO?
  13. How can providers access their data in the PSO?
  14. Will my peers be able to access my data in the PSO?
  15. How do I become a PSO member?
  16. What is the cost of joining the PSO?


What is a PSO?

A PSO is an organization or a component of an organization that meets certain criteria established in the Patient Safety Rule of the Federal Department of Health and Human Services. PSOs primarily conduct activities to improve patient safety and healthcare quality. A PSO's workforce analyzes patient safety events, such as the identification, analysis, prevention and reduction or elimination of the risks and hazards associated with the delivery of patient care (See 42 CFR 3.102 for the complete list of requirements).

What is the purpose of a PSO?

The Patient Safety Rule establishes a framework by which hospitals, doctors and other healthcare providers can voluntarily report information to PSOs on a confidential basis, for the aggregation and analysis of patient safety events.
The Patient Safety Rule outlines how PSOs can be a source of confidential and privileged external advice for healthcare providers seeking to understand and minimize the risks and hazards in delivering patient care.

What is patient safety work product (PSWP)?

PSWP is the data or documents assembled for and submitted to a PSO. PSWP is protected by the Patient Safety Act and the Patient Safety Rule. PSWP may identify the providers involved in a particular patient safety event and/or a provider employee that reported the information about the patient safety event. PSWP may also include patient data that is considered protected health information as defined by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (see 45 CFR 160.103).

Examples of PSWP include subjective reports, staff impressions and/or other objective facts not part of mandatory reporting. Subject to certain specific exceptions, PSWP cannot be used in criminal, civil, administrative or disciplinary legal proceedings.

What documents might be considered PSWP?

The following documents ARE considered PSWP:

  • Peer review documents
  • Clinical practice protocols
  • Staff evaluations
  • Equipment review logs
  • Root cause analyses
  • Quality and safety reports
  • Committee minutes, deliberations or recommendations, checklists, notes or outcome data

What documents would NOT be considered PSWP?

The following documents are NOT considered PSWP:

  • Patients records
  • Billing information
  • Mandatory reporting data
  • Discharge information
  • Information related to a criminal act
  • Original patient or provider information

What are patient safety activities?

  • The following are the patient safety activities typically carried out by or on behalf of a PSO:
  • Efforts to improve patient safety and the quality of care delivery
  • The collection and analysis of patient safety work product (PSWP)
  • The development and dissemination of information regarding patient safety (i.e., recommendations, protocols, or information regarding best practices)
  • The use of PSWP as a means to encourage a culture of safety as well as for providing feedback to effectively minimize patient risk
  • The maintenance of procedures to preserve the confidentiality and security of PSWP
  • Activities related to the operation of a patient safety evaluation system
  • The provision of feedback to participants in a patient safety evaluation system

Do PSOs receive federal funding?

No, PSOs do not receive any federal funding.

Why are the terms safety and quality used together when describing the role of PSOs?

The term safety refers to reducing risk from harm and injury, while the term quality suggests striving for excellence and value. By addressing common, preventable adverse occurrences, a healthcare setting can become safer, thereby enhancing the quality of care delivered. PSOs create a secure environment where clinicians and healthcare organizations can collect and analyze data, thus identifying and helping to reduce the risks and hazards associated with patient care and improving quality.

What are the benefits to healthcare providers who work with a PSO?

PSOs serve as independent experts, who can collect and analyze PSWP on a local, regional and national level to develop insights into the root causes of patient safety events. Communications with PSOs are protected which helps to diminish fears of liability risk related to the analysis of patient safety events.

The protections of the Patient Safety Rule enable PSOs that work with multiple providers to examine the number of patient safety events that are needed to better understand the root causes of harm from adverse events and to develop more reliable information on how best to improve patient safety.
Patient Safety Organizations, n.d., in Agency for Healthcare Research (AHRQ), retrieved September, 2013.

In some states, assisted living (AL) communities are not considered healthcare providers. Will these AL communities be protected under the Patient Safety Act?

PSWP gathered by facilities not considered healthcare providers is NOT protected under the Patient Safety Act. NCAL's outside legal counsel has developed checklists for NCAL members to use to determine if their AL community would be covered as a provider under the Patient Safety Act.

What data will be collected in the PSO?

A quality improvement data collection tool has already been endorsed and approved by the NCAL Quality Committee. This data collection tool measures hospital readmissions, the off-label use of antipsychotics, and the number of pressure ulcers and hospice utilization. Member organizations will additionally be able to submit PSWP related to patient safety events and near misses* for analysis and feedback for improving patient safety.

*Near misses are patient safety events that that would have occurred if not for pre-error identification and intervention.

How will data be submitted in the PSO?

Data collection tools are available for electronic submission. Reports will be generated at routine intervals so that AL communities can track their improvement and benchmark results regionally and nationally.

How can providers access their data in the PSO?

Data will be password protected through a secure Web site as required by law. Providers will determine their unique permissions, which will either enable or limit access at a corporate or individual level.

Will my peers be able to access my data in the PSO?

As required by law, all data is protected and can only be accessed by authorized users.

How do I become a PSO member?

The National PSO for Assisted Living application process is easy. Simply complete the contact us form to request a contract.  Once the contract is reviewed and signed and payment is received you are a PSO member.

What is the cost of joining the PSO?

To keep the costs to communities as low as possible, NCAL will be covering the start-up costs so that communities will only incur an annual fee to participate. Annual PSO membership fees are as follows:

Communities with 4-25
residential units*
$35 per residential unit with a minimum annual fee of $250
Communities with 26+
residential units*
$35 per residential unit with a maximum annual fee of $3,500
Multi-community**
entities with 100+ residential units*
$3,500 for the first two communities and $800 for each additional community

*A residential unit is defined as a separate apartment or unit for one or more persons. Such unit may include its own kitchen, bathroom, and sleeping area or bedroom.

**Multi-community entities with less than 100 units shall pay $35 per unit with an annual maximum fee of $3,500

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