Form #5 Form #5 Attachment G: PSO Profile Form

Form Approved

OMB No.: 0935-0143
Exp. Date: 11/30/2021

PATIENT SAFETY ORGANIZATION (PSO) 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. This form is designed to collect a minimum level of voluntary data necessary to develop
aggregate statistics relating to PSOs, the types of providers they work with, and their general location in the US. The
PSO Profile is intended to be completed annually by all PSOs that are “AHRQ-listed” during any part of the previous
calendar year. This information is collected by AHRQ’s PSO Privacy Protection Center (PSOPPC) and is used to
populate the AHRQ PSO selection tool on the AHRQ PSO website, to generate slides presented at the PSO Annual
Meeting, and to develop content for the AHRQ National Healthcare Quality and Disparities Report.
Follow these instructions to ensure successful completion and submission of the PSO Profile:
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Caref ully read over each question to ensure that information for the appropriate period is provided. The PSO
Prof ile should reflect information from the previous calendar year, unless otherwise noted in the question.
Caref ully 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.
Answer text is required for all “please specify” answer selections.

A Level 2 account on the PSOPPC Web site (www.psoppc.org) is needed to electronically complete and submit the PSO
Profile. Please contact [email protected] for more information about registering for an account.
PSO Name

Reporting Year

AHRQ-assigned PSO Number

Form Completed By

Today’s Date

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Burden Statement
Public reporting burden for the collection of information is estimated to average 1 hour 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.

PSO PROFILE: PSO CHARACTERISTICS
PLEASE NOTE:
The Patient Safety and Quality Improvement Final Rule defines a component organization and a component PSO as
f ollows:



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 component PSO may be a separate legal entity from its parent organization(s).
1.

Which of the following categories best describes the PSO?
•

If the PSO is itself a legal entity, select the answers that best describe the PSO, whether or not it is a component PSO.

•

If the PSO is a component PSO that is not a legal entity, select the answers that best describe the PSO’s parent
organization

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: ___________________________________________________________________________

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2.

Which of the following geographic areas is the PSO available to serve?
Select Only One:
 The PSO is available to serve any provider in all 50 states and the US territories. Proceed to Question 3.
 The PSO only serves a closed network of specific providers. Please select the states the network provides services in below:
 If the PSO is available to serve providers only in specific states and US territories, select all that apply below:

States:
 Alabama

 Montana

 Alaska

 Nebraska

 Arizona

 Nevada

 Arkansas

 New Hampshire

 California

 New Jersey

 Colorado

 New Mexico

 Connecticut

 New York

 Delaware

 North Carolina

 Florida

 North Dakota

 Georgia

 Ohio

 Hawaii

 Oklahoma

 Idaho

 Oregon

 Illinois

 Pennsylvania

 Indiana

 Rhode Island

 Iowa

 South Carolina

 Kansas

 South Dakota

 Kentucky

 Tennessee

 Louisiana

 Texas

 Maine

 Utah

 Maryland

 Vermont

 Massachusetts

 Virginia

 Michigan

 Washington

 Minnesota

 West Virginia

 Mississippi

 Wisconsin

 Missouri

 Wyoming

Federal District and U.S. Territories:
 American Samoa
 District of Columbia
 Guam
 Northern Marianas Islands
 Puerto Rico
 Virgin Islands

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3.

Is the PSO currently willing to conduct patient safety activities in any/all clinical disciplines, medical specialties and subspecialties?
 Yes
 No
If the answer above is “Yes,” please proceed to Question 5.

4.

If the PSO conducts patient safety activities ONLY in certain clinical disciplines, primary medical specialties or subspecialties, please
select the ones that your PSO focuses on from the list below.
Select All That Apply:
 Anesthesiology
 Dentistry
 Dermatology
 Emergency medicine/EMS
 Family medicine
 Internal medicine
 Neurology
 Neurological surgery
 Nuclear Medicine
 Nursing
 Obstetrics/Gynecology
 Ophthalmology
 Oral and maxillofacial surgery
 Oncology
 Pathology
 Pediatrics
 Pharmacology/Pharmacy
 Physical medicine and rehabilitation
 Psychiatry
 Radiology (diagnostic and interventional)
 Surgery
 Urology
 Vascular surgery
 If the clinical disciplines, primary medical specialties or
subspecialties your PSO focuses on are not listed above,
please specify them here: _______________________________

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5.

Does the PSO provide any of the following resources/services?
Select All That Apply:
 Alerts/advisories

 Online resources

 Analysis support for adverse events

 Patient safety culture assessment and training

 Comparative reports

 Safe Tables/ Safety Huddles

 Consulting

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

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

 Toolkits

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

 Other, please specify: _____________________

PSO PROFILE: PARTICIPATING PROVIDERS
PLEASE NOTE:
The term “provider” has a specific definition in the Patient Safety and Quality Improvement Rule at section 3.20. The
f ollowing categories – “individual” and “institutional” - apply to two types of providers included within this definition. Use
these categories for the purpose of answering question 6:
Individual providers include offices of practitioners licensed or otherwise authorized under state law to provide health care
services (e.g., doctor, nurse, dentist, psychologist, psychotherapist, etc.) with five or fewer such practitioners.
Institutional providers include all other types of providers licensed or otherwise authorized under state law to provide
health care services (such as ambulance services, behavioral health services, hospitals, home health care, pharmacy,
skilled nursing facility, urgent care, etc.), including offices with six or more practitioners.
Count individual facilities under a health system or management contract as separate institutional providers.
6.

During the previous calendar year, which type(s) of providers has the PSO worked with?
Institutional providers:
How many institutional providers did your PSO work with?
If none, are you willing to work with institutional providers?

 Yes  No

Individual providers:
How many individual providers did your PSO work with?
If none, are you willing to work with individual providers?

 Yes  No

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PSO PROFILE: PATIENT SAFETY WORK PRODUCT
7.

What is the PSO’s current method for receiving Patient Safety Work Product (PSWP)?
Select All That Apply:
 Electronic (e.g., standard file format)
 Paper
 Other (e.g., email or phone)

8.

Which of the following Common Formats are currently being used by the PSO?
Select All That Apply:
 Common Formats for Event Reporting – Hospital Version 1.2
 Common Formats for Event Reporting – Hospital Version 2.0
 Common Formats for Event Reporting – Community Pharmacy Version 1.0
 Common Formats for Event Reporting – Nursing Home Version 1.0
 None

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PROVIDER PROFILE
PLEASE NOTE:
The Provider Profile requests additional information about the providers with which the PSO works.
1.

Please select all HHS regions reflecting the location of any providers that worked with your PSO in the previous calendar year:
Select All That Apply:
 Region 1
Connecticut, Maine, Massachusetts, New Hampshire,
Rhode Island, and Vermont

 Region 6
Arkansas, Louisiana, New Mexico, Oklahoma, and
Texas

 Region 2
New Jersey, New York, Puerto Rico, and the Virgin
Islands

 Region 7
Iowa, Kansas, Missouri, and Nebraska

 Region 3
Delaware, District of Columbia, Maryland, Pennsylvania,
Virginia, and West Virginia

 Region 8
Colorado, Montana, North Dakota, South Dakota,
Utah, and Wyoming

 Region 4
Alabama, Florida, Georgia, Kentucky, Mississippi, North
Carolina, South Carolina, and Tennessee

 Region 9
Arizona, California, Hawaii, Nevada, American
Samoa, Commonwealth of the Northern Mariana
Islands, Federated States of Micronesia, Guam,
Marshall Islands, and Republic of Palau

 Region 5
Illinois, Indiana, Michigan, Minnesota, Ohio, and
Wisconsin

 Region 10
Alaska, Idaho, Oregon, and Washington

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PROVIDER PROFILE: ALL PROVIDER TYPES
2.

Please select all of the type(s) of providers the PSO has worked with during the previous calendar year. For each type selected, write
in the number of providers of that type that the PSO has worked with.

Type(s) of Providers

How Many?

 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.

_______________

 Long term acute care hospital

_______________

 Mail order pharmacy

_______________

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

_______________

 Office of licensed/state-authorized practitioners (such as doctor, nurse, dentist,
psychologist, physiotherapist, etc.) with six or more such practitioners

_______________

 Outpatient clinic/services/care

_______________

 Psychiatric hospital

_______________

 Rehabilitation hospital

_______________

 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:
_________________________________________________________________

_______________

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PROVIDER PROFILE: HOSPITALS ONLY
PLEASE NOTE:
Questions 3, 4, and 5 below apply only to hospitals (of any type) that worked with your PSO in the previous
calendar year. This includes critical access hospitals, general (acute care) hospitals, long term acute care
hospitals, psychiatric hospitals, rehabilitation hospitals, specialty hospitals, and any other types of hospitals.
3.

4.

5.

Select the licensed bed sizes of all of the hospitals your PSO worked with in the previous calendar year and specify
how many hospitals your PSO worked with in each licensed bed size category.

Licensed Bed Size
Categories

How Many Hospitals?

 1 – 25

______________________

 26 – 49

______________________

 50 – 99

______________________

 100 – 199

______________________

 200 – 299

______________________

 300 – 399

______________________

 400 – 499

______________________

 500 +

______________________

Select the appropriate ownership categories for the hospitals your PSO worked with in the previous calendar year
and specify how many hospitals your PSO worked with in each category.
Ownership Categories

How Many Hospitals?

 Government (Federal, State, or local)

__________________

 Private, for-profit

__________________

 Private, non-profit

__________________

 Public, non-profit

__________________

 Unknown

__________________

 Other, please specify:
___________________________________________

__________________

Select the statement that best describes the academic affiliation status of the hospitals your PSO worked with during
the previous calendar year and provide the number of hospitals in each category.
Academic Affiliation Categories

How Many Hospitals?

 Hospitals that are part of an academic medical center

__________________

 Teaching hospitals that are not part of an academic medical
center

__________________

 Hospitals that have no medical trainees or medical school
affiliations

__________________

 Unknown

__________________

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