Attachment I
Form Approved
OMB No.: 0935-0143
Exp. Date: XXXXX
PATIENT SAFETY ORGANIZATION: PROFILE |
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OVERVIEW AND INSTRUCTIONS |
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The Agency for Healthcare Research and Quality (AHRQ), of the Department of Health and Human Services (HHS), administers the provisions of the Patient Safety and Quality Improvement Act (PSQIA) dealing with Patient Safety Organization (PSO) operations. AHRQ’s PSO Privacy Protection Center (PSOPPC) collects the information in the PSO Profile that PSOs submit voluntarily on the types of heath care providers, settings, and reports for which PSOs conduct patient safety activities. The PSO Profile is intended to be completed annually by all PSOs that are “AHRQ-listed” during any part of the previous calendar year. Follow these instructions to ensure successful completion and submission of the PSO Profile:
A Level 2 account on the PSOPPC Web site (www.psoppc.org) is needed to electronically complete and submit the PSO Profile. Please contact support@psoppc.org for more information about registering for an account. If you prefer to submit a hard copy, please send to: PSOPPC, ActioNet, Inc., 3110 Lord Baltimore Dr., Suite 104, Baltimore, MD 21244. |
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PSO Name
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AHRQ-assigned PSO Number |
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Reporting Year
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Form Completed By |
Today’s Date |
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PSO PROFILE: PSO CHARACTERISTICS |
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PLEASE NOTE: The Patient Safety and Quality Improvement Final Rule defines a component organization and a component PSO as follows:
A parent organization may need to create a component organization focused on patient safety and healthcare quality in order to meet criteria for PSO listing. A component PSO may be a separate legal entity from its parent organization(s). |
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1. |
Is the PSO a component PSO?
Select One:
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2. |
Which of the following best describes the PSO (or if the component PSO is not a separate legal entity, please describe its parent(s))?
Select All That Apply:
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3. |
Which of the following categories best describes the PSO (or if the component PSO is not a separate legal entity, please describe its parent(s))?
Select All That Apply:
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4. |
Does the PSO have a specific specialty focus? Specialties below include all relevant subspecialties.
Select All That Apply:
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5. |
Which of the following geographic areas is the PSO available to serve?
Select One:
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6. Does the PSO provide any of the following resources/services? Select All That Apply:
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PLEASE NOTE: The Patient Safety and Quality Improvement Rule outlines eight specific activities as patient safety activities.These activities include:
In carrying out patient safety activities, PSOs are involved in efforts to improve the quality of healthcare delivery. |
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7. |
Does the PSO offer any service other than patient safety activities (as defined in the Patient Safety and Quality Improvement Act)? Select One:
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8. |
Since the PSO was first listed, for which of the following areas has the PSO received reports? Select One:
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PSO PROFILE: PROVIDER CONTRACTS |
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PLEASE NOTE: The term “provider” has a specific definition in the Patient Safety and Quality Improvement Rule at section 3.20. The following categories – “individual” and “institutional” - apply to two types of providers within the Rule’s definition. Use these categories for the purpose of answering questions 9 and 10: Individual providers include offices of licensed/state-certified practitioners (such as doctor, nurse, dentist, psychologist, psychotherapists, etc.) with five or fewer such practitioners. Institutional providers include all other types of providers (such as ambulance services, behavioral health services, hospitals, home health care, pharmacy, skilled nursing facility, urgent care, etc.), as well as offices of licensed/state-certified practitioners with six or more such practitioners. |
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9. |
During the previous calendar year, how many individual and/or institutional provider contracts did the PSO have for services pursuant to the Patient Safety and Quality Improvement Act? If the number of contracts is not available, enter “NA”. If none, enter “0”. Total contracts: Individual contracts:
Institutional contracts: |
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10. |
One institutional contract may represent multiple institutional providers (e.g., ambulance services, retail pharmacies, urgent care, etc.). How many institutional providers are covered by the institutional contracts listed in Question 9? |
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11. |
Of the provider contracts reported in Question 9, from how many contracts were reports submitted to the PSO during the previous calendar year? If the number of contracts is not available, enter “NA”. If none, enter “0”. |
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PSO PROFILE: PATIENT SAFETY DATA |
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12. |
Since the PSO was first listed, how many patient safety reports has the PSO received? If not available, enter “NA”, and if none, enter “0”. If “NA” or “0”, skip to the Provider Profile.
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13. |
Since the PSO was first listed, what type of patient safety reports have been submitted to the PSO? Select All That Apply:
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14. |
Since the PSO was first listed, what format has been used for the patient safety reports submitted to the PSO? Select One:
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15. |
Please specify all categories of AHRQ Common Formats patient safety events that have been collected since the PSO was first listed:
Select All That Apply:
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16. |
Since the PSO was first listed, has the PSO successfully submitted patient safety event data (excluding test records) to the PSOPPC, including submission through a vendor?
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PROVIDER PROFILE PSOs that answered “0” or “NA” for the above PSO Profile questions 9, 11, and 12 need not complete the Provider Profile. The Provider Profile requests further information about each of the providers with which the PSO has a contract pursuant to the Patient Safety and Quality Improvement Act (PSQIA). If the providers include health systems of multiple hospitals or other facilities, and/or hospitals that include other facilities owned/operated by the hospital (e.g., free standing ambulatory surgery center or long term care facility), the PSO should complete a Provider Profile for each individual facility. A Level 2 account on the PSOPPC Web site (www.psoppc.org) is needed to electronically complete and submit the Provider Profile for each provider. Please contact support@psoppc.org for more information about registering for an account. If you prefer to submit a hard copy, please send to: PSOPPC, ActioNet, Inc., 3110 Lord Baltimore Dr., Suite 104, Baltimore, MD 21244. |
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First three digits of provider’s zip code: _________ |
PSO-assigned Provider ID Code: ____________________________
The PSO-Assigned Provider ID Code is a surrogate provider ID that the PSO assigns to each of its contracted healthcare provider(s) to protect the anonymity of the healthcare provider(s).
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1. |
Type of provider.
Select One:
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PROVIDER PROFILE
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2. |
To be completed for any hospitals and/or skilled nursing facility/long term care facility (if any):
What was the number of licensed beds at the end of the most recent calendar year for which data are available? _______________
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3. |
What is the provider’s ownership status?
Select One:
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4. |
To be completed for hospitals only (general or specialty):
Academic Affiliation Is this provider part of an academic medical center or is this provider affiliated with a teaching program?
Select One:
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Burden Statement Public reporting burden for the collection of information is estimated to average 3 hours 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, 5600 Fishers Lane, Mail Stop Number 07W41A, Rockville, MD 20857.
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Patient Safety Organization (PSO) Profile: 2015 Paper Form |
Subject | Patient Safety Organizations (PSOs) complete the PSO Profile form annually to provide information to HHS on the types of health |
Author | PSOPPC |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |