How To Maintain a PSO Listing

Once a PSO is listed, AHRQ recommends that PSOs review AHRQ's expectations and requirements.

Once listed as a PSO, AHRQ recommends that PSO's review AHRQ's expectations and requirements. Two helpful sources are Patient Safety Organizations: A Compliance Self-Assessment Guide and AHRQ's Frequently Asked Questions. Essentially, there are two categories of required tasks to maintain PSO listings: tasks to perform during each three-year period and tasks to perform to preparefor re-listing.

View Sample Filing Timeline

During each three-year period, PSOs must:

Enter at least two bona fide contracts within each 24-month period.

PSOs must enter at least two bona fide contracts with two different healthcare providers for the receipt and review of patient safety work product. Each PSO is required to notify AHRQ that it meets this requirement by submitting the Two Bona Fide Contracts Requirement form no later than 45 days before the end of each succeeding 24-month period following its initial period of listing. If the PSO has not met the requirement or failed to submit the form, the PSO will receive a notice of deficiency and will be given until midnight of the last day of the 24-month period to enter the two contracts and submit the form. If the PSO does not meet the requirement, it will receive a notice of revocation and delisting.

Throughout the listing period, PSOs should:

Make Updates to the PSO Profile

Update PSO Profile information online by February 28th each year. For example, data reflecting the 2013 reporting period (i.e., 2013 calendar year) should be submitted no later than February 28, 2014. This information should be entered electronically via PSO Privacy Protection Center Web site. Please contact for more information about registering for an account.

To submit a hard copy, please send the completed form to: PSOPPC, ActioNet, Inc., 3110 Lord Baltimore Dr., Suite 104, Baltimore, MD 21244.

Review the Disclosure Statement Requirements

Every time the PSO enters a Patient Safety Act contract with a provider, PSOs will need to determine whether the PSO needs to submit a Disclosure Statement. AHRQ recommends contacting the PSO Program to determine how and if this form is necessary. The disclosure statement consists of two sections: one which describes the relationship that exists between the PSO and the provider apart from any Patient Safety Act contracts, and one which explains why the PSO can still fairly and accurately perform the required patient safety activities.

File the disclosure form only if:

  • The PSO has other contractual, financial or reporting relationships with a contracting provider beyond the scope of what is prescribed in the Patient Safety Rule.


  • The PSO is not managed, operated or controlled independently from the contracting provider.

Review the PSO Compliance Self-Assessment Guide

The Compliance Self-Assessment Guide provides an overview of the activities necessary for PSOs to maintain listed status. This guide can also help PSOs prepare for compliance reviews by AHRQ, which may be announced or unannounced. To help prepare for a compliance review and consider how well the PSO is meeting the standards, review Patient Safety Organizations: A Compliance Self-Assessment Guide.

Submit the PSO Change of Listing Information Form

The Change of Listing Information Form is an administrative form which is used by a PSO to revise information on PSO Authorized Official and Point of Contact, the PSO and parent contact information, including changes to addresses, telephone numbers, and Web sites. As required in the Patient Safety Rule, section 3.102(a)(vi), a PSO must promptly notify the Secretary during its period of listing if there have been any changes in the accuracy of the information submitted for listing, along with the pertinent changes.  It is required that the Authorized Official of record sign this form. See "What is the Role of the PSO Authorized Official."

To maintain listing for another three years, PSOs must:

Complete the Certification for Continued Listing

Each PSO must file the Certification for Continued Listing no later than 75 days before expiration of the 3-year listing period. A PSO should begin this process by reviewing its operations as it enters its third year of listing. The Certification for Continued Listing form leads users through a series of attestations regarding the accuracy of information provided about the PSO. Essentially, PSOs will need to confirm whether or not the PSO is performing the activities required by the Patient Safety Rule. Confirm whether or not the originally submitted information is still accurate.

Sample questions to be verified include:

  • Is the PSO performing activities to improve patient safety?

  • Is the PSO using PSWP to encourage sharing of patient safety data and feedback?

  • Is the PSO preserving the confidentiality of PSWP?

Before submitting the form, the PSO will be asked to schedule a call with AHRQ to review the PSO's progress in meeting those requirements. This discussion will take place approximately six months before the listing expires. Keep in mind that component PSOs must address additional questions, such as showing that it maintains PSWP separately from its parent organization.

Page last reviewed February 2021
Page originally created January 2014

Internet Citation: How To Maintain a PSO Listing. Content last reviewed February 2021. Agency for Healthcare Research and Quality, Rockville, MD.

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