Form #5 Form #5 Attachment H: PSO Profile Form

Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats

Attachment.I.PSO Profile.Form__AHRQ.11.2017

Information Form - Revised

OMB: 0935-0143

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Attachment I


Form Approved

OMB No.: 0935-0143

Exp. Date: XXXXX




PATIENT SAFETY ORGANIZATION:

PROFILE

OVERVIEW AND INSTRUCTIONS


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:

  • Carefully read over each question to ensure that information for the appropriate period is provided. The PSO Profile should reflect information from the previous calendar year, unless otherwise noted in the question.

  • Carefully review all definitions of terms provided to ensure all questions are answered accurately.

  • Follow skip logic instructions when prompted.

  • The PSO Profile is intended to be submitted to the PSOPPC between January 1st and February 28th of each year and can be updated as necessary thereafter.

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.

PSO Name



AHRQ-assigned PSO Number

Reporting Year



Form Completed By

Today’s Date

PSO PROFILE: PSO CHARACTERISTICS

PLEASE NOTE:

The Patient Safety and Quality Improvement Final Rule defines a component organization and a component PSO as follows:

  • A component organization is a unit or division of a legal entity or an entity that is owned, managed, or controlled by one or more legally separate parent organizations.

  • A component PSO is a PSO listed by the Secretary that is a component organization.

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).

1.

Is the PSO a component PSO?



Select One:



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



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:



Federal, state, local, or tribal government agency

For-profit entity



Nonprofit entity

Other, please specify:


________________________________________





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:



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



Consortium of medical centers


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


Consumer (advocacy) organization


Financial services organization


Healthcare provider organization; includes health system, hospital, physician group, and any other type of provider,

laboratory, tissue bank, and any other type of auxiliary service


Insurer (other than health insurance issuer)


Pharmacy services organization


Practice management organization


Software development organization


University or other educational establishment


Wholesaler/retailer; includes general purchasing organization, wholesaler or similar entity; Durable Medical Equipment

(DME) supplier, retail pharmacy, other retailer or similar entity


Other, please specify: ___________________________________________________________________________







4.



Does the PSO have a specific specialty focus? Specialties below include all relevant subspecialties.



Select All That Apply:



All medical specialties

Pulmonology

Anesthesiology

Radiology, including vascular and interventional

Cardiology

Thoracic surgery

Colorectal surgery

Urology

Dentistry (e.g., Dentists, Specialists, Assistants, Hygienists)

, including oral surgery (C084)

Vascular surgery

Including oral surgery

Dermatology


Allied Health Professionals, please specify:

Emergency medicine/EMS

________________________________________

Family medicine

Other, please specify:

Gastroenterology

________________________________________

General surgery


Internal medicine


Neurology


Neurological surgery


Nuclear Medicine


Nursing


Obstetrics/Gynecology


Ophthalmology


Orthopedic surgery


Otolaryngology


Pathology


Pediatrics


Pediatric surgery


Pharmacy


Physical medicine and rehabilitation


Plastic surgery


Podiatry


Psychiatry







































































5.

Which of the following geographic areas is the PSO available to serve?



Select One:

National

State and/or territory







Select All That Apply:









Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Northern Marianas Islands

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Virgin Islands

Washington

West Virginia




Wisconsin (C164)

Wyoming




6. Does the PSO provide any of the following resources/services?

Select All That Apply:

Alerts/advisories

Newsletters

Analysis support for adverse events

Online resources

Comparative reports

Patient safety culture assessment and training

Consulting

Technical assistance (e.g., expert on-call) (C10support)

Educational opportunities (e.g., webinars on patient safety topics)

Toolkits

Networking events (e.g., access to subject matter experts)

Other, please specify: (C01_______________________




PLEASE NOTE:

The Patient Safety and Quality Improvement Rule outlines eight specific activities as patient safety activities.These activities include:

  • Efforts to improve patient safety and the quality of healthcare delivery

  • The collection and analysis of patient safety work product

  • The development and dissemination of information with respect to improving patient safety

  • The utilization of patient safety work product for the purposes of encouraging a culture of safety and providing feedback and assistance to effectively minimize patient risk

  • The maintenance of procedures to preserve confidentiality with respect to patient safety work product

  • The provision of appropriate security measures with respect to patient safety work product

  • The utilization of qualified staff

  • Activities related to the operation of a patient safety evaluation system and to the provision of feedback to participants in a patient safety evaluation system

In carrying out patient safety activities, PSOs are involved in efforts to improve the quality of healthcare delivery.

7.

Does the PSO offer any service other than patient safety activities (as defined in the Patient Safety and Quality Improvement Act)?

Select One:

Yes

No

If yes, please describe: _____________________________________________________________________________




8.

Since the PSO was first listed, for which of the following areas has the PSO received reports?

Select One:

Quality

Safety

Both



PSO PROFILE: PROVIDER CONTRACTS

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.

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:









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?






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”.








PSO PROFILE: PATIENT SAFETY DATA



12.



Shape1 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.




13.



Since the PSO was first listed, what type of patient safety reports have been submitted to the PSO?

Select All That Apply:



Electronic (e.g., standard file format)

Paper

Other (Email or phone)








14.



Since the PSO was first listed, what format has been used for the patient safety reports submitted to the PSO?

Select One:

AHRQ’s Common Formats

Another format

Both




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:



Blood or Blood Product

Perinatal

Device, including Health Information Technology (HIT)

Pressure Ulcer

Fall

Surgery or Anesthesia

Healthcare-associated Infection (HAI)

Venous Thromboembolism (VTE)

Medication and/or Other Substance


Other, please specify: _____________________________________________________________________




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?

Yes

No






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.



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).


1.

Type of provider.



Select One:



Ambulance, emergency medical technician, paramedic services, etc.

Ambulatory surgery center

Assisted living facility

Behavioral health services

Critical access hospital

Federally qualified health center

General (acute care) hospital

Home health care; includes in-home treatment services, hospice care, etc.

Independent laboratory, freestanding diagnostic or imaging center, tissue bank, etc.

Mail order pharmacy

Office of licensed/state-certified practitioner(s) (such as doctor, nurse, dentist, psychologist, physiotherapist, etc.) with
five or fewer such practitioners








Office of licensed/state-certified practitioners (such as doctor, nurse, dentist, psychologist, physiotherapist, etc.) with
six or more such practitioners; includes community health center, group practice, clinic, etc. with six or more practitioners

Outpatient clinic/services/care

Retail pharmacy

Skilled nursing or intermediate/long term care facility

Specialized treatment facility; includes renal dialysis center, chemotherapy center, etc.

Specialty or other hospital

Urgent care/Emergency medicine

Other, please specify: ______________________________________________________________________





PROVIDER PROFILE




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? _______________




3.



What is the provider’s ownership status?



Select One:

Government (Federal, State, or Local)

Private, for-profit

Private, non-profit

Public, non-profit

Unknown

Other, please specify: ___________________________________________________________________








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:

Yes, this provider is part of an academic medical center

Yes, this provider 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




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 Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePatient Safety Organization (PSO) Profile: 2015 Paper Form
SubjectPatient Safety Organizations (PSOs) complete the PSO Profile form annually to provide information to HHS on the types of health
AuthorPSOPPC
File Modified0000-00-00
File Created2021-01-21

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