Patient Safety Act: HHS Is in the Process of Implementing the Act, So Its Effectiveness Cannot Yet Be Evaluated
Released: 2010-01-29T00:00:00

Letter

Background

AHRQ and the Office for Civil Rights (OCR) within HHS share responsibility for implementing the Patient Safety Act. AHRQ is responsible for listing PSOs, providing technical assistance to PSOs, implementing and maintaining the NPSD, and analyzing the data submitted to the NPSD. OCR has responsibility for interpreting, implementing, and enforcing the confidentiality protections. To help implement the Patient Safety Act, AHRQ and OCR developed the legislation’s implementing regulations, which took effect January 19, 2009.

The Patient Safety Act establishes criteria that organizations must meet and required patient safety activities that the organizations must perform after being listed as PSOs. The criteria include an organizational mission to improve patient safety and the quality of health care delivery; use of collected data to provide direct feedback and assistance to providers to minimize patient risk; staff who are qualified to perform analyses on patient safety data; and adequate policies and procedures to ensure that patient safety data are kept confidential. Required PSO activities include activities such as efforts to improve patient safety and the quality of health care delivery. (See app. II for the complete list of criteria and required PSO activities as specified in the Patient Safety Act.) The criteria allow for many types of organizations to apply to AHRQ to be listed as a PSO. These organizations may include public and private entities, for-profit and not- for-profit organizations, and entities that are a component of another organization, such as a hospital association or health system.

A PSO must attest for the initial listing period that it will comply with the criteria and that it has policies and procedures in place that will allow it to perform the required activities of a PSO. When reapplying for subsequent 3-year listing periods, a PSO must attest that it is complying with the criteria and that it is in fact performing each of the required activities. The regulations require AHRQ staff to review written PSO applications documenting PSO attestations to each of the statutory criteria and required activities. In the case of certain PSOs that are component organizations, the regulations also require the applicant to complete an additional set of attestations and disclosure statements detailing the relationship between the component and parent organizations. The regulations require that after AHRQ staff review the application materials and related information, the applicant will be listed, conditionally listed, or denied.

Legal Protections for Patient Safety Data

When a provider elects to use the services of a listed PSO, the Patient Safety Act provides privilege and confidentiality protections for certain types of data regarding patient safety events that providers collect for the purposes of reporting to a PSO. In general, the Patient Safety Act excludes the use of patient safety data in civil suits, such as those involving malpractice claims, and in disciplinary proceedings against a provider. While certain states have laws providing varying levels of privilege and confidentiality protections for patient safety data, the Patient Safety Act provides a minimum level of protection.

Regulations implementing the Patient Safety Act address the circumstances under which patient safety data may be disclosed, such as when used in criminal proceedings, authorized by identified providers, and among PSOs or affiliated providers. OCR has the authority to conduct reviews to ensure that PSOs, providers, and other entities are complying with the confidentiality protections provided by the law. OCR also has the authority to investigate complaints alleging that patient safety data has been improperly disclosed and to impose a civil money penalty of up to $11,000 per violation.

The NPSD and Requirements for Submitting Data to the NPSD

The Patient Safety Act requires HHS to create and maintain the NPSD as a resource for PSOs, providers, and qualified researchers. The law specifies that the NPSD must have the capacity to accept, aggregate, and analyze non-identifiable patient safety data voluntarily submitted to the NPSD by PSOs, providers, and other entities. Providers may submit non- identifiable data directly to the NPSD, or work with a PSO to submit patient safety data. Neither PSOs nor providers are required by either the Patient Safety Act or regulation to submit data to the NPSD. Figure 1 shows the intended flow of patient safety data and other information among providers, PSOs, and the NPSD.

The Patient Safety Act authorizes HHS to develop common formats for reporting patient safety data to the NPSD. According to the Patient Safety Act, these formats may include the necessary data elements to be collected and provide common and consistent definitions and a standardized computer interface for processing the data. While most U.S. hospitals have some type of internal reporting system for collecting data on patient safety events, they often have varying ways of collecting and organizing their data. This variation makes it difficult to accurately compare patient safety events across systems and providers and can be a barrier to developing solutions to improve patient safety. If providers or PSOs choose to submit patient safety data to the NPSD, AHRQ requires that these data be submitted using the common formats, because using the common formats is necessary so that data in the NPSD can be aggregated and analyzed. Aggregation and analysis of data is important for developing the “lessons learned” or “best practices” across different institutions that may help improve patient safety.

The Patient Safety Act and its implementing regulations provide additional measures PSOs must follow whether or not they intend to submit the data they collect to the NPSD. The Patient Safety Act regulations require PSOs to collect patient safety data from providers in a standardized manner that permits valid comparisons of similar cases among similar providers, to the extent to which these measures are practical and appropriate. To meet this requirement, the regulation specifies that PSOs must either (1) use the common formats developed by AHRQ when collecting patient safety data from providers, (2) utilize an alternative format that permits valid comparisons among providers, or (3) explain to AHRQ why it would not be practical or appropriate to do so. The Patient Safety Act also requires any data regarding patient safety events that is submitted to the NPSD be non-identifiable. According to the Patient Safety Act, users can access non-identifiable patient safety data only in accordance with the confidentiality protections established by the Patient Safety Act. The Patient Safety Act’s regulations provide technical specifications for making patient safety data non-identifiable.

Finally, the Patient Safety Act states AHRQ must analyze the data that are submitted to the NPSD and include these analyses in publicly available reports. Specifically, under the Patient Safety Act, AHRQ is required to submit a draft report on strategies to improve patient safety to the IOM within 18 months of the NPSD becoming operational and a final report to Congress 1 year later. The Patient Safety Act requires this report to include effective strategies for reducing medical errors and increasing patient safety, as well any measures AHRQ determines are appropriate to encourage providers to use the strategies, including use in any federally funded programs. In addition, the Patient Safety Act states HHS must use data in the NPSD to analyze national and regional statistics, including trends and patterns of health care errors, and include any information resulting from such analyses in its annual reports on health care quality.

AHRQ Has Listed PSOs, but Few PSOs We Interviewed Have Begun Serving Providers

AHRQ listed 65 PSOs from November 2008 to July 2009. However, few of the 17 PSOs we randomly selected to interview had entered into contracts or other business agreements with providers to serve as their PSO, and only 3 PSOs reported having begun receiving patient safety data or providing feedback to providers. PSO officials identified several reasons why they have not yet engaged with providers. Some PSOs are still establishing various aspects of their operations; some are waiting for the common formats for collecting patient safety data to be finalized by AHRQ; and some are still engaged in marketing their services and educating providers about the federal confidentiality protections offered by the Patient Safety Act.

As of July 2009, AHRQ Had Listed 65 PSOs Representing a Variety of Organizations

Although the regulations implementing the Patient Safety Act did not become effective until January 19, 2009, AHRQ began listing PSOs earlier, in November 2008. By July 2009, AHRQ had listed 65 PSOs in 26 states and the District of Columbia. AHRQ officials told us that in listing PSOs they accepted PSOs’ attestations that the PSOs met the certification requirements established in the Patient Safety Act—that is, to be a listed PSO, an entity must have policies and procedures in place to perform the required activities of a PSO and will comply with additional criteria for listing. For continued listing beyond the initial period, PSOs must attest that they have contracts with more than one provider and are in fact performing each of the required activities.

The 65 PSOs AHRQ had listed represent a wide range of organizations, including some that provided patient safety services for many years prior to being listed as well as new organizations specifically established to function as a PSO under the Patient Safety Act. AHRQ officials told us that the organizations listed as PSOs include consulting firms that have provided patient safety services for a range of providers and specialties, as well as organizations with a focus on patient safety in a specific area such as medical devices, hand hygiene, or pediatric anesthesia. The listed PSOs also include vendors of patient safety reporting software and components of state hospital associations.

AHRQ officials told us that the services PSOs deliver to individual providers will likely vary, depending on the specific contractual or other business agreements the PSOs establish with providers. For example, a small hospital may want to contract with a PSO to provide all its internal quality improvement services, while a large hospital may just contract with a PSO to obtain the legal protections under the Patient Safety Act and to contribute data to the NPSD. While officials of 13 of the 17 PSOs we interviewed indicated they provided some patient safety services prior to being listed, all 17 PSOs stated that the services they planned to make available included the collection and analysis of patient safety data, the de- identification of patient safety data for submission to the NPSD, feedback, and patient safety training.

Few Listed PSOs We Interviewed Have Begun to Serve Providers

While AHRQ has listed 65 PSOs, few PSOs we interviewed have entered into contracts or other business agreements with providers to serve as their PSO. Only 4 of the 17 listed PSOs we interviewed had any contracts or other agreements with providers to serve as their PSO. Furthermore, according to PSO officials, only 3 of these PSOs had begun to receive patient safety data or provide feedback to providers. PSO officials identified several reasons why they had yet to begin working with providers and receiving patient safety data as of July 2009. These reasons include the following: The need to complete the development of various components of their business operations. Some PSO officials we interviewed told us they still need to determine various components of their operations. For example, officials from some PSOs told us they have yet to determine their fee structure for working with providers. Officials from 6 of 17 PSOs we interviewed stated they were or would be contracting with other PSOs to receive services, such as information technology systems support or data security. Nine PSOs reported they had not yet determined whether they would be contracting for some services. In addition, while officials from most of the PSOs we interviewed indicated they planned to submit patient safety data to the NPSD, 4 had not yet determined how they will make data non-identifiable before sending it to the NPSD.

The need to obtain AHRQ’s final common formats for collecting data on patient safety events. Officials from some PSOs we interviewed indicated they needed the common formats to be finalized by AHRQ before beginning to work with providers. While use of AHRQ’s common formats to collect data from providers is not required under the regulations, most PSOs we interviewed plan to use the common formats for collecting data on patient safety events and submitting these data to the NPSD. Officials from 7 of the 17 PSOs we interviewed said they plan to require providers to submit data using the common formats, and 4 PSOs said they will not require them of providers but will either convert the reports they receive to the common formats or adapt their existing reporting system to include the common formats.

The need to educate providers about the federal confidentiality protections. Officials from several of the 17 PSOs we interviewed told us they faced challenges in addressing provider concerns related to the scope of the confidentiality protections and that these concerns needed to be addressed before providers would be willing to engage the services of a PSO. Some of these PSO officials described challenges in communicating details of the confidentiality protections. According to AHRQ officials, the rules for when, where, and how patient safety data are protected from disclosure are both complex and interrelated with the privacy rules for protected health information under HIPAA. AHRQ officials acknowledged the need to work with PSOs to clarify the rules governing the confidentiality of patient safety data so PSOs can better communicate these to providers. AHRQ officials indicated they would address these issues in upcoming quarterly conference calls they hold with PSO representatives. (See appendix I for examples of ways established patient safety reporting systems communicate legal protections for providers and the data they submit.)

AHRQ Is in the Process of Implementing the NPSD and Has Developed Preliminary Plans for Using NPSD Data

AHRQ is in the process of implementing the NPSD and developing its associated components that are necessary before the NPSD can receive patient safety data—(1) the common formats PSOs and providers will be required to use if submitting patient safety data to the NPSD and (2) a method for making these data non-identifiable. If each of these components is completed on schedule, AHRQ officials expect that the NPSD could begin receiving patient safety data from hospitals in February 2011. AHRQ officials could not provide a time frame for when they expect the NPSD to be able to receive patient safety data from other providers. AHRQ also has preliminary plans for how to allow the NPSD to serve as an interactive resource for providers and PSOs and for how AHRQ will analyze NPSD data to help meet its reporting requirements under the Patient Safety Act.

AHRQ Is in the Process of Developing the NPSD, the Common Formats for Hospitals to Submit Data to the NPSD, and a Method for Making Data Non- identifiable

AHRQ is in the process of developing the NPSD, and AHRQ officials expect that the NPSD could begin receiving patient safety data from hospitals by February 2011. Specifically, AHRQ established a 3-year contract with Westat effective September of 2007 to develop the NPSD, which is being set up as a database that AHRQ officials stated is essential for meeting the requirements of the act. AHRQ and Westat officials told us that completion of the NPSD depends on both the development of the common formats that will be used to submit patient safety data to the NPSD and on the development of a method for making the data non- identifiable. If each of these components is completed on schedule, AHRQ officials expect that the NPSD could begin to receive patient safety data from hospitals by February 2011.

AHRQ is finalizing the common formats that PSOs and hospitals will be required to use if submitting patient safety data to the NPSD. AHRQ officials expect that the common formats could be available for hospitals to use in submitting data electronically to the NPSD by September 2010. AHRQ began developing the common formats for hospitals in 2005 by reviewing the data collection methods of existing patient safety systems. In 2007, AHRQ contracted with the National Quality Forum (NQF) to assist with the collection and assessment of public comments on a preliminary version of the common formats that was released in August 2008. These common format forms are used to collect information on patient safety events, including information about when and where an event occurred, a description of the event, and patient demographic information. AHRQ issued the common formats for hospitals in paper form in September 2009, and is in the process of making electronic versions available for hospitals and PSOs to use when submitting data to the NPSD. Specifically, AHRQ officials told us that they are in the process of developing technical specifications that private software companies and others can use to develop electronic versions of the common formats. According to AHRQ officials, hospitals and PSOs will need these electronic versions of the common formats in order to submit data to the NPSD. Their current project plan indicates that the technical specifications will be completed by March 2010. AHRQ officials estimate that electronic versions of the common formats could be available to hospitals and PSOs by September 2010.

AHRQ officials stated that they expect eventually to develop common formats for providers in other health care settings, such as nursing homes and ambulatory surgical centers. Furthermore, AHRQ officials told us that that they plan on developing future versions of the common formats capable of collecting data from the results of root cause analyses that providers may conduct. However, AHRQ officials were unable to provide an estimate for when the common formats for other providers will be available or when the capability to collect information from root cause analyses will be available.

The Patient Safety Act also requires that data submitted to the NPSD be made non-identifiable by removing information that could be used to identify individual patients, providers, or facilities. To help PSOs and providers meet this requirement, AHRQ contracted with the Iowa Foundation for Medical Care (IFMC) to operate a PSO Privacy Protection Center (PPC) that will develop a method for making patient safety data non-identifiable and assist PSOs and providers by removing any identifiable patient or provider information from the data before submission to the NPSD. Current AHRQ and PPC project plans indicate that the PPC should be ready to receive and make patient safety data non- identifiable beginning in September 2010. AHRQ officials told us that this process involves not only removing information from each record that could be used to identify patients, providers, or reporters of patient safety information, but also determining whether identities could be determined from other available information and using appropriate methods to prevent this type of identification from occurring. AHRQ officials told us that PPC officials are working with experts to develop the PPC’s method for making data non-identifiable.

AHRQ officials stated that their rationale for establishing the PPC was to determine a method for making data non-identifiable, provide a cost savings for PSOs, encourage data submission to the NPSD, and create consistency in the non-identifiable data that are submitted to the NPSD. According to AHRQ officials, the PPC will provide its services to PSOs at no charge and will submit non-identifiable patient safety data on behalf of PSOs to the NPSD. However, PSOs are not required to use the PPC and may choose to make their patient safety data non-identifiable internally or with the help of a contractor of their choice.

AHRQ project plans indicate that the PPC will be able to submit data to the NPSD beginning in February 2011, approximately 5 months after the PPC begins receiving data from hospitals. AHRQ officials stated that this time period is necessary, in part, because the PPC needs to begin receiving data before it can determine if its method for rendering data non- identifiable is appropriate or needs to be adjusted. For example, if the PPC receives a sufficient volume of data, then officials expect to be able to submit data on individual patient safety events and have it remain non- identifiable. If the volume of data is too low, however, PPC officials expect to have to aggregate data from individual events so that it remains non- identifiable once submitted to the NPSD, in which case AHRQ officials stated they may delay submission of data to the NPSD until a sufficient volume is received. AHRQ officials noted that it is impossible to determine in advance the volume of data that will be submitted to the PPC due to the voluntary nature of submissions. As a result, the level of detail that will exist in the NPSD data cannot be determined in advance of data being received and processed by the PPC. Figure 2 summarizes key dates in AHRQ’s efforts to develop the NPSD and its related components.

AHRQ Has Preliminary Plans For How to Meet Requirements for Use of NPSD Data, Though AHRQ Officials Have Identified Limitations to the Types of Analyses That Will Be Conducted

The Patient Safety Act requires that the NPSD serve as an interactive resource for providers and PSOs, allowing them to conduct their own analyses of patient safety data. To meet this requirement, AHRQ has developed plans to allow providers to query the NPSD to obtain information on patient safety events, including information on the frequencies and trends of such events. AHRQ’s contract with Westat to construct the NPSD includes a series of tasks for developing, testing, and implementing this interactive capability of the NPSD. The contract specifies that these interactive capabilities will be available within 12 months of the NPSD beginning to receive patient safety information. Based on AHRQ’s estimate that the NPSD may be operational by February 2011, the interactive capabilities of the NPSD could be available by February 2012. However, AHRQ officials indicated that they had not yet determined the specific types of information that will be available to PSOs and providers as this will depend, in part, on the level of detail that is included in the NPSD data after the data are made non-identifiable.

The Patient Safety Act also states that HHS must use the information reported into the NPSD to analyze national and regional statistics, including trends and patterns of health care errors, and to identify and issue reports on strategies for reducing medical errors and increasing patient safety after the NPSD becomes operational. To do this, AHRQ has developed preliminary plans for analyzing the data that will be submitted to the NPSD. According to AHRQ officials, these plans specify how the agency will analyze NPSD data to determine trends and patterns, such as the frequency with which certain types of adverse events happen across providers based on the data they may submit to the NPSD. However, AHRQ has yet to develop plans for more detailed analyses of NPSD data that could be useful for identifying strategies to reduce medical errors. Officials explained that these plans will not be developed until the NPSD begins receiving data and they are able to determine the level of detail in the data and what analyses it will support.

Despite the potential for standardization provided by the common formats, AHRQ officials have identified important limitations in the types of analyses that can be performed with the data submitted to the NPSD. For example, AHRQ officials explained that because submissions to the NPSD are voluntary, the trends and patterns produced from the NPSD will not be nationally representative and, therefore, any analyses conducted cannot be used to generate data that are generalizable to the entire U.S. population. In addition, officials stated that the results from some analyses may be unreliable because there is no way to control for duplicate entries into the NPSD, which could occur if a provider submits a single patient safety event report to more than one PSO. Finally, AHRQ officials noted that it will be difficult to determine the prevalence or incidence of adverse events in specific populations. They told us that determining prevalence or incidence rates requires information on the total number of people at risk for such events, and that the patient safety data submitted to the NPSD will not include this information. (See appendix I for more information about the ways established patient safety reporting systems analyze data to develop solutions that improve patient safety.)

Concluding Observations

AHRQ is still in the early stages of listing PSOs and developing plans for how it will analyze NPSD data and report on effective strategies for improving patient safety, as required under the Patient Safety Act. As a result, we cannot assess whether, or to what extent, the law has been effective in encouraging providers to voluntarily report data on patient safety events and to facilitate the development and adoption of improvements in patient safety. In addition, because improvements to patient safety depend on the voluntary participation of providers and PSOs, it remains uncertain whether the goals of the Patient Safety Act will be accomplished even after AHRQ completes its implementation. For example, providers will have to decide whether to work with a PSO and the extent to which they will report patient safety data to both the PSO and the NPSD. Whether the process results in specific recommendations for improving patient safety will depend on the volume and quality of the data submitted and on the quality of the analyses conducted by both PSOs and by AHRQ. Finally, if these recommendations are to lead to patient safety improvements, providers must recognize their value and take actions to implement them.

Agency Comments

The Department of Health and Human Services reviewed a draft of this report and provided technical comments, which we have incorporated as appropriate.

We will send copies of this report to the Secretary of Health and Human Services and other interested parties. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov.

If you or your staff have questions about this report, please contact me at (202) 512-7114 or kohnl@gao.gov. Contact points for our Office of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff members who made key contributions to this report are listed in appendix III.

Appendix I: Examples from Established Patient Safety Reporting Systems

Because the Agency for Healthcare Research and Quality’s (AHRQ) efforts to list Patient Safety Organizations and implement the Network of Patient Safety Databases are relatively new but some other patient safety reporting systems are already established, we identified examples of how selected established patient safety reporting systems encourage reporting of patient safety event information by providers and facilitate the development of improvements in patient safety. We judgmentally selected five established patient safety reporting systems from a list of such systems compiled by AHRQ. We selected systems that collected data for learning purposes and that appeared in a literature review we conducted of 45 relevant articles in peer-reviewed, trade, or scholarly publications published since January 2000. After selecting the systems, we conducted structured interviews with representatives of these systems to identify examples of ways that these systems encouraged providers to submit patient safety data for analysis and used the data collected by their systems to help develop improvements in patient safety. The system representatives we interviewed provided common examples that we have grouped into four areas: Practices that encourage providers to learn from patient safety data, rather Communication intended to clearly explain legal protections for providers and the data they submit; Data collection tools intended to standardize the data providers submit; Data analyses that produce actionable feedback.

Practices that encourage providers to learn from patient safety data, rather than blame individuals. Representatives from all five patient safety reporting systems we reviewed said their systems encourage providers to learn from patient safety data as a way to improve patient safety, and not blame individuals for an event. According to system representatives, one way they did this was to emphasize the value of the data collected by the system for learning ways to reduce the risk that a certain event will recur. For example, representatives from one system said they created posters to hang in health care facilities from which the system collected patient safety data. Representatives from this system explained that the posters described a patient safety event about which the system received data as well as the solutions the system developed to improve patient safety. Another practice representatives said they used is allowing providers to submit data anonymously. Four out of five system representatives said their systems offered providers a way to submit data anonymously.

Communication intended to clearly explain legal protections for providers and the data they submit. Many of the representatives we interviewed from patient safety reporting systems told us that their systems communicate information intended to clearly explain the legal protections afforded providers and the patient safety data they submit. For example, one system in our review provided guidance for providers on how to clearly label data to invoke the confidentiality protections associated with patient safety data under a law that protects data in this system. Representatives from another patient safety reporting system told us that communicating information about available legal protections can be particularly important for systems that collect data from providers in multiple states, because the legal protections for providers and patient safety data vary from state to state. For example, representatives from two patient safety reporting systems with users in multiple states said their systems provided customized legal information for providers based on the state confidentiality laws that applied to each provider’s location. A representative from one of these systems also said that the legal information the system offered helped providers understand what types of data to submit and encouraged them to submit it.

Data collection tools intended to standardize the data providers submit. Representatives from all five systems told us they had developed tools intended to standardize the data providers submit to their patient safety databases. For some systems these tools include common formats and computer systems. Some of the representatives explained that standardizing the information providers submit helps ensure that patient safety events, especially events involving clinical terms, are classified in the same way. Some representatives also said that if a system did not define clinical terms for providers, providers may define events differently, which can limit the system’s ability to analyze submitted patient safety data. Furthermore, the representatives said, standardizing terms increased the value of the data as it is aggregated, as well as any resulting analyses. Representatives from all five systems said the ability to collect and aggregate standardized patient safety data allowed them to identify patterns in patient safety events, which they believed enabled their systems to suggest ways to improve patient safety.

Some system representatives said that standardizing the way providers submit patient safety data allowed them to streamline the data collection process for providers. Some representatives said they designed their data collection protocols to allow providers to fulfill additional reporting requirements related to accreditation or quality improvement functions, such as submitting data regarding certain patient safety events to the Joint Commission. Representatives from one system said that their systems did this to make collecting and submitting patient safety data more efficient for providers and thereby increase the likelihood that providers would submit such data to the patient safety reporting system. In another example, one system built a feature into its computer program that allowed providers to transfer data directly from providers’ in-house databases to the patient safety data collection system, a data collection method system representatives said accounted for approximately 40 percent of all data received from providers.

Data analyses that produce actionable feedback. Representatives from all five patient safety reporting systems told us that their systems analyzed submitted data to develop actionable steps providers could implement to improve patient safety. According to the representatives, their systems aggregated data from provider submissions and used these data for both quantitative analyses, such as trend or frequency analyses, and qualitative analyses, which examine narrative data to determine whether there were any common themes across events. Representatives from all five systems said they used both qualitative and quantitative analyses because neither method alone was completely sufficient to develop improvements to patient safety. For example, one system’s representatives said they conducted qualitative analyses such as using a computer program to analyze and group the narrative data providers submitted to learn about the factors that contributed to patient safety events. The same representatives explained that their system also conducted quantitative analyses such as trend analyses on events to see how often they occur.

Representatives from all the systems said they used various methods to encourage providers to implement the improvements to patient safety the systems helped develop. Examples of methods they used included sending an e-mail from the system when new content was published on the system’s Web site, hosting Web conferences, and publishing analyses in trade or scholarly publications. All the representatives said their systems collaborated with other organizations to increase the likelihood that the improvements they developed were implemented. For example, one system worked with a statewide coalition of organizations in the quality improvement field to encourage providers to implement the patient safety improvements the system developed.

Appendix II: Selected Statutory Requirements for Listing of Patient Safety Organizations

GAO Contact:

Staff Acknowledgments:

In addition to the contact named above, William Simerl, Assistant Director; Eric R. Anderson; Eleanor M. Cambridge; Krister Friday; Kevin Milne; and Andrea E. Richardson made key contributions to this report.