Attachment B -- PSO Form 10-21-2010

Form Approved

OMB No. 0935-0143    

Exp. Date 08/31/2011

PATIENT SAFETY ORGANIZATION INFORMATION FORM

Before completing this form, please review the requirements of the Patient Safety Rule specified in 42 CFR Part 3, especially sections 3.102 (a), 3.102 (c), and 3.106. The rule implements the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), which authorizes the creation of Patient Safety Organizations (PSOs). The Agency for Healthcare Research and Quality (AHRQ), of the Department of Health and Human Services (HHS), administers the provisions of the Patient Safety Act dealing with PSO operations. The rule and other PSO-related information are available on AHRQ’s PSO Web site at www.pso.ahrq.gov. Completion of this form provides information to HHS on the types of health care settings with which PSOs are working to conduct patient safety activities. This form is designed to collect data to report aggregate statistics on the impact of the Patient Safety Act; no PSO-specific data will be released. Please report this information by February 15th of the year following that to which the information pertains. For example, data from calendar year 2009 should be reported by February 15, 2010. This information can be entered electronically at AHRQ’s PSO Privacy Protection Center www.psoppc.org. Please contact support@psoppc.org for more information. To submit a hard copy, please send to: PSO PPC, IFMC, 1776 West Lakes Parkway, West Des Moines, IA, 50266. PSO NAME: _____________________________________________________________________________________________________ AHRQ PSO ASSIGNED NUMBER: _________________________________ REPORTING YEAR: ______________________________ FORM COMPLETED BY:___________________________________________________________________________________________ FORM SUBMISSION DATE: ________________________________________________________________________________________

Part A: PSO Information Please note that the information requested in Part A is to be completed once for the PSO.

In this report year, how many provider organizations did the PSO have a contract or agreement for services with pursuant to the Patient Safety Act? Count each contract or agreement only once regardless of how many facilities each contract or agreement covered. If none, enter “0” From how many of these provider organizations did the PSO receive PSWP at any time during this report year? If none, enter “0” From how many provider organizations, with which the PSO did not have a contract or agreement to receive PSWP, did it receive PSWP in this report year? If none, enter “0”

1. _________ 2. _________ 3. _________

4. Which of the following categories best describes the type of PSO (or, if a component PSO, type of principal parent)? Select One:



Healthcare provider organization; includes hospital, physician group, and any other types of provider; laboratory, tissue bank, and any other type of auxiliary service



Association; includes medical society and any other type of professional association; trade association; voluntary association



Consulting firm; includes research institute (except if part of an educational establishment), data analysis firm, etc.



Software development organization



University or other educational establishment



Consumer (advocacy) organization



Financial service organization or insurer (other than health insurance provider)



Publishing, media company; includes any type of information service



Wholesaler/retailer; includes general purchasing organization, wholesaler or similar entity; DME supplier, retail pharmacy, other retailer or similar entity



Other, please specify: _____________________________________________________________________________________

Part A: PSO Information – continued

5.

For purposes of patient safety reporting, does the PSO focus on a particular type of patient safety event or area, or does it accept event reports on any topic/category? Select One:



Accepts only reports on a single topic



Accepts reports on multiple topics, but not all topics



No specific focus; accepts all safety event reports

6.

In which particular category does the PSO accept reports? Select All That Apply:



Blood or Blood Product



Device or Medical Surgical Supply



Fall



Healthcare-associated Infection



Medication or Other Substance



Perinatal



Pressure Ulcer



Surgery or Anesthesia



PSO does not focus on any particular category



Other, please specify: ______________________________________________________________________________________

7.

With respect to arranging to receive PSE reports from providers, does the PSO focus on defined categories other than the event-specific Common Formats in the previous question? Select One:



Yes, please specify: ______________________________________________



No

8.

Which of the following legal or organizational forms best describes the PSO? Select One:



Federal, state, local, or tribal government agency



For-profit entity



Non-profit entity; includes foundation, university, etc.



Other

9.

Is the PSO is a component of a parent organization? Select One: If the answer is “No”, please proceed to question 11. If the answer is “Yes, it is a separate legal entity” or “Yes, but it is not a separate legal entity”, please proceed to question 10.



Yes, it is a component and a separate legal entity



Yes, it is a component , but it is not a separate legal entity



No, it is not a component PSO

10.

Which of the following legal or organizational forms best describes the principal parent organization? Select First Applicable:



Federal, state, local, or tribal government agency



For-profit entity



Non-profit entity; includes foundation, university, etc.



Other

11.

Was the PSO established as a direct result of state law or regulation? Select One:



Yes



No

12.

Does the PSO offer any service other than PSO services (as described in the rule)? Select One:



Yes



No

13.

From what geographical area does the PSO receive event reports? Select One:



National



One or more states, but not national (list states) __________________________________________________________________



PSO does not receive patient safety data/event reports

Part B: Provider(s) Information Please note that the information requested in Part B is to be completed for each provider that a PSO has a contract with (e.g. If a PSO has contracts with five providers, Part B should be filled out for each of the providers). The information requested in Part A is to be completed only once for the PSO.
First three digits of provider’s zip code: _________________________			PSO assigned provider ID: _________________________
1.	Type of provider. Select One:
	 General (acute care) hospital  Specialty or other hospital  Not a hospital, please specify: _____________________________________
2.	What was the number of staffed beds at the end of the most recent calendar year for which data are available? Round to the nearest 100: ____________________
3.	What was the total number of inpatient discharges during the most recent calendar year for which complete data are available? Round to the nearest 1,000: ____________________
4.	What was the combined total number of inpatient and outpatient surgical operations during the most recent calendar year for which complete data are available? Round to the nearest 1,000: ____________________
5.	What was the number of outpatient encounters during the most recent calendar year for which complete data are available (include emergency department outpatient encounters)? Round to the nearest 1,000: ____________________
6.	What was the number of live births during the most recent calendar year for which complete data are available? Round to the nearest 100: ____________________
7.	Is this reporting provider part of an academic medical center or affiliated with a teaching program? Select One:
		Yes – is part of an academic medical center
		Yes – has a teaching affiliation, but is not part of an academic medical center; includes teaching facility through which students, interns, residents, etc. rotate
		No
		Unknown
8.	In what size area is the reporting provider located? Select One:
		Large metropolitan area (1,000,000 or more population)
		Small metropolitan area (50,000 to 999,999 population)
		Micropolitan area (10,000 to 49,999 population)
		Non-urban area (Less than 10,000 population)

	PART B: Provider(s) Information – continued
9.	What is the reporting provider’s ownership status? Select One:
				Government (federal, state, or local)
				Private, not-for-profit
				Private, for-profit (investor-owned)
				Other, please specify: ____________________________________________________________
10.	Does the reporting provider currently participate in the CDC National Healthcare Safety Network for surveillance of healthcare associated infections? Select One:
	 Yes  No  Unknown
11.	Does the reporting provider have a designated person responsible for patient safety (e.g., patient safety manager or officer, or risk manager)? Select One:
		Yes, at least one person assigned full-time to patient safety
		Yes, less than one full-time person assigned to patient safety
		No one designated specifically for patient safety
		Unknown
12.	Is the reporting provider part of a multi-facility system (MFS)? Select One: If the answer is “Yes”, please proceed to question 13. If the answer is “No”, this form is complete.  Yes  No
13.	If the reporting provider is part of an MFS, check all the facility types that are part of the system.
			Hospital			Home health agency
			Nursing home			Retail establishment, includes pharmacy
			Assisted living			Other, please specify: __________________________________________________________
			Ambulatory care or clinic
This completed form is considered public information.
Burden Statement Public reporting burden for the collection of information is estimated to average 30 minutes per response.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:  AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

PSO Information Page 4 of 4