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

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 1^st and February 28^th 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.

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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