Exhibit A – Policies for Participation
1. Shared Registry Data Ownership
Each practice entity (hospital, physician group, or physician) owns the data that it submits to the SVS PSO, and is entitled to specify and control the use of its data in the manner set forth in the contract. The SVS PSO may use such data for quality improvement activity and may release non-identifiable aggregated summaries (data combined from all sites) without the prior consent of the practice entity. However, any release of practice entity specific non-identifiable data on a per procedure level must be approved by the practice entity.
The following principles guide the function of the SVS PSO and must be adhered to by all participants.
a. All activities of the SVS PSO must be consistent with the purpose of the PSO, as stated in its governing documents.
b. Each physician member must submit data for all consecutive procedures in the modules in which they participate that are recorded by the SVS PSO and must agree to submit office claims data on a periodic basis to allow an audit to ensure accurate and complete data entry.
c. Each member hospital agrees to submit ICD-9 based claims data on a periodic basis to allow an audit to ensure accurate and complete data entry.
d. Each member hospital and physician must submit complete data forms, including all elements of the SVS PSO registry for all eligible procedures, using a web-based system approved by the SVS PSO, including follow-up data at one year, or other time points established by the SVS PSO.
e. Each member hospital and physician agrees that Patient Safety Work Product including any comparative data can never be disclosed or used for competitive marketing. Hospitals and physicians own their own data, and can download and publish such data and indicate that it was derived from their participation in the SVS PSO. However, they may not publish Patient Safety Work Product provided in benchmarking reports that compares their hospital or practice with other groups in the SVS PSO.
f. Each SVS PSO hospital and physician member agrees to follow all regulations contained within the Hospital Insurance Portability and Accountability Act (HIPAA) and the Patient Safety Quality Improvement Act (PSQIA). This includes, but is not limited to not disclosing any patient, hospital or provider identifiable information.
g. Failure to adhere to these policies may result in loss of membership in SVS PSO for a hospital or physician, if so determined by a majority vote of the Governing Council.
(Updated June 2015)