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

Form Approved

OMB No.: 0935-0143

Exp. Date: ??/??/????

PATIENT SAFETY ORGANIZATION (PSO) PROFILE
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 dealing with Patient Safety Organizations (PSO) operations. Completion of this form provides information to HHS on the types of health care providers, settings, and reports for which PSOs conduct patient safety activities. This form is designed to collect data that will be used to generate aggregate statistics necessary to administer the Patient Safety and Quality Improvement Act and to report on the Act’s impact. The PSO Profile form is intended for use by all PSOs that are “AHRQ-listed” during any part of the current reporting period. PSOs that submitted the PSO Profile form last year, should expect to verify the accuracy of that submission and make updates as needed. Last year’s submission can be updated online without reentering all of the prior information in order to help meet this year’s deadline. Please submit this information by February 28th each year for the prior calendar year (i.e., the “reporting period”). For example, data reflecting the 2013 reporting period (i.e., 2013 calendar year) should be submitted by February 28, 2014. This information should be entered electronically at AHRQ’s PSO Privacy Protection Center (PSOPPC) Web site www.psoppc.org. Please contact [email protected] for more information about registering for an account. 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
PART A: PSO PROFILE Please note that the information requested in Part A is to be completed only once per year for the PSO. Responses should reflect PSO information for the prior calendar year.
1.	How many institutional and/or individual provider contracts did the PSO have for services pursuant to the Patient Safety and Quality Improvement Act? If a contract is with a corporate entity of multiple institutional providers, please use ‘1’ as the number for each of the institutional providers. If none, enter “0”. Total Contracts: Institutional providers (all types of providers defined in part B, Question 1 other than physician groups of fewer than 6 providers): Individual providers (Individual physicians and physician groups of fewer than 6):
2.	From how many of these provider contracts were reports submitted to the PSO? If none, enter “0”.			__________
3.	Did the PSO receive patient safety work product (PSWP) from any provider with which the PSO did not have an agreement/contract?  Yes  No

PART A: PSO PROFILE – continued
4. Is you	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
5. Which of the follow	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: includes foundation, university, etc.  Other
6.	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
		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 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)
		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: __________________________________________________________________________________
7.	How many patient safety reports did the PSO receive? If none, enter “0” and skip questions 8-12.
8.	For which of the following areas has the PSO received reports? Select One:  Quality  Safety  Both
9.	What type of patient safety reports are submitted to the PSO? Select All That Apply:  Electronic (e.g., standard file format)  Paper  Other (Email or phone)
10.	What format was used for the patient safety reports submitted to the PSO? Select One:  AHRQ’s Common Formats  Another format  Both

PART A: PSO PROFILE – continued

11.

Please specify all categories of patient safety events that have been collected:

Select All That Apply:

 Anesthesia  Medical/Surgical Supply

 Blood or Blood Product  Medication and/or Other Substance

 Device  Perinatal

 Fall  Pressure Ulcer

 Healthcare-associated Infection (HAI)  Surgery

 Health Information Technology (HIT)  Venous Thromboembolism (VTE)

 Other, please specify: _______________________________________________________________________

12.

Has the PSO submitted Patient Safety Event data to the PSOPPC?

 Yes

 No

13.

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

Select All That Apply:

 All medical specialties  Anesthesiology  Cardiology  Colorectal surgery  Dentistry, including oral surgery  Dermatology  Emergency medicine  Family medicine  Gastroenterology  General surgery  Internal medicine  Neurology  Neurological surgery  Nursing  Obstetrics/Gynecology  Ophthalmology  Orthopedic surgery  Otolaryngology  Nuclear Medicine  Pathology  Pediatrics  Pediatric Surgery  Pharmacy  Physical Medicine & Rehabilitation  Plastic surgery  Podiatry  Psychiatry  Pulmonology  Radiology, including vascular and interventional

 Thoracic surgery  Urology  Vascular surgery  Allied Health Professionals, please specify: ________________________________________________  Other, please specify: ________________________________________________

PART A: PSO PROFILE – continued

14.

What geographic area does the PSO serve?

Select One:



National

 State and/or territory

Select All That Apply:

 Alabama  American Samoa  Arkansas  Colorado  Delaware  Florida  Guam  Idaho  Indiana  Kansas  Louisiana  Maryland	 Alaska  Arizona  California  Connecticut  District of Columbia  Georgia  Hawaii  Illinois  Iowa  Kentucky  Maine  Massachusetts
 Michigan  Mississippi  Montana  Nevada  New Jersey  New York  North Dakota  Ohio  Oregon  Puerto Rico  South Carolina  Tennessee  Utah  Virginia  Washington  Wisconsin	 Minnesota  Missouri  Nebraska  New Hampshire  New Mexico  North Carolina  Northern Marianas Islands  Oklahoma  Pennsylvania  Rhode Island  South Dakota  Texas  Vermont  Virgin Islands  West Virginia  Wyoming

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

Select All That Apply:

 Educational opportunities (e.g., webinars on patient safety topics)  Technical assistance (e.g., expert on-call support)

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

 Analysis support for adverse events  Other, please specify: _____________________

16.

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

Select One:

 Yes

 No

If yes, please describe:

PART B: PROVIDER PROFILE Part B requests further information about each of the providers with which the PSO has a contract pursuant to the Patient Safety and Quality Improvement Act. If a PSO has a contract with a health system that includes multiple hospitals or other facilities, please complete Part B for each facility in the system that currently submits, or intends to submit, information to your PSO. Likewise, if the PSO has a contract with a hospital that includes other facilities owned/operated by the hospital (e.g., free standing ambulatory surgery center or long term care facility) the PSO should complete Part B for each facility owned/operated by the hospital that currently submits, or intends to submit, information to the PSO. PSOs that do not have any agreements/contracts with providers need not complete Part B.
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:
		General (acute care) hospital
		Specialty or other hospital
		Skilled nursing or intermediate/long term care facility
		Office of licensed/state-certified practitioner(s) (such as doctor, dentist, psychologist, physiotherapist, etc.) with five or fewer such practitioners
		Office of licensed/state-certified practitioners (such as doctor, dentist, psychologist, physiotherapist, etc.) with six or more such practitioners; includes community health center, group practice, clinic, etc. with six or more practitioners
		Ambulatory surgery center
		Independent laboratory, freestanding diagnostic or imaging center, tissue bank, etc.
		Specialized treatment facility; includes renal dialysis center, chemotherapy center, etc.
		Ambulance, emergency medical technician, paramedic services, etc.
		Home health care; includes in-home treatment services, hospice care, etc.
		Retail pharmacy
		Other, please specify: ____________________________________________________________________________________­
2.	Size of metropolitan area in which provider is located. See the National Center for Health Statistics Urban-Rural Classifications (http://www.cdc.gov/nchs/data_access/urban_rural.htm) Select One:
		Large metropolitan area or large fringe metropolitan area (1,000,000 or more population)
		Medium metropolitan area (250,000 to 999,999 population)
		Small metropolitan area (50,000 to 249,999 population)
		Micropolitan area (10,000 to 49,999 population)
		Noncore area (Less than 10,000, neither metropolitan nor micropolitan)

PART B: PROVIDER PROFILE – continued
3.	To be completed for each hospital and skilled nursing facility/long term care facility (if any): Provider size (for hospitals and/or skilled nursing facilities/long term care only) What was the number of licensed beds at the end of the most recent calendar year for which data are available? _______________ Enter number of beds rounded to the nearest 100. NOTE: For hospitals with fewer than 100 beds, please enter the whole number without rounding (e.g., for a hospital with 75 beds, please enter “75”).
4.	What is the provider’s ownership status? Select One:
		Government (Federal, state, or local)
		Private, nonprofit
		Private, for-profit
		Unknown
		Other, please specify: _____________________________________________________________________________________
5.	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, 540 Gaither Road, Room #5036, Rockville, MD 20850.

Attachment H – PSO Profile 7