How To Maintain a PSO Listing
When a PSO is listed by AHRQ, it should be ready to carry out its mission and primary activity: conducting activities with providers to improve patient safety and the quality of health care delivery. By the time the PSO is due to submit its first Certification of Continued Listing, it must be able to accurately certify that it is currently performing, and will continue to perform, all eight required patient safety activities.
The forms containing the certifications needed to maintain a PSO listing are available for online submission, which is encouraged. Once a PSO is listed, online forms pre-populate with the PSO's administrative information. PSO Authorized Officials can access online forms for their PSO by logging in to their My PSO Account page. If necessary, forms can be downloaded from AHRQ's PSO website, completed, and submitted by email or regular mail.
The AHRQ PSO Division is readily available to respond to PSO questions and technical assistance needs. The Division is also available to facilitate technical assistance with the HHS Office for Civil Rights (OCR) specific to the confidentiality requirements for patient safety work product.
During each three-year listing period, PSOs must:
Submit the Two Bona Fide Contracts Form within each 24-month period
PSOs must have at least two bona fide contracts with two different providers for the purpose of receiving and reviewing patient safety work product. The 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. Only the completed form (not the contracts) is required as long as it is submitted before the deadline. If the PSO fails to submit the form by the deadline, it will receive a notice of a preliminary finding of deficiency and will be required to provide copies of contracts to AHRQ that demonstrate compliance.
Submit the Change of Listing Information Form whenever listing information changes
A PSO must promptly notify AHRQ whenever there are changes in the accuracy of the information submitted for listing and provide the pertinent changes. This includes any changes to any information in the last Certification of Listing Form the PSO submitted to AHRQ, including but not limited to: the PSO's Authorized Official and Point of Contact, addresses, telephone numbers, and websites for the PSO; and any changes related to new or existing parent organization(s) to the PSO. The Change of Listing Information Form is an administrative form that can be used by the PSO’s Authorized Official to comply with this notification requirement.
Submit a Disclosure Statement whenever a relationship with a provider arises that requires disclosure
The PSO must submit a Disclosure Statement to AHRQ within 45 days whenever it has begun, or begins, with respect to the same provider, both a Patient Safety Act contract and a relationship that meets one or more of the criteria in subsection 3.102(d)(2) of the Patient Safety Rule. If a PSO believes this requirement may apply, the Authorized Official is encouraged to contact AHRQ for technical assistance before beginning work on a Disclosure Statement.
To prepare for continued listing for another three years, PSOs must:
Submit the Certification for Continued Listing Form
Each PSO must submit the Certification for Continued Listing Form no later than 75 days before expiration of its current three-year listing period. The Certification for Continued Listing Form includes a series of attestations regarding the current activities of the PSO. The PSO may find it helpful to review its operations in relation to the questions on the Continued Listing Form as it enters the third year of each listing period to ensure that it understands and will be able to accurately attest to all of the required certifications. For example, the PSO must be performing all of the eight required patient safety activities. It must also have policies and procedures specific to its own operations that address the confidentiality and security requirements, including a provision to notify providers if their information was subject to an unauthorized disclosure or security breach.
Throughout listing, PSOs are encouraged to:
Submit and update the PSO Profile Form
The PSO Profile Form is voluntary and unrelated to required certifications for listing, but AHRQ encourages all PSOs listed during any part of the previous calendar year to submit a PSO Profile Form to the PSO Privacy Protection Center (PSOPPC) by February 28 of each year. For example, data reflecting the 2021 reporting period (i.e., 2021 calendar year) should be submitted no later than February 28, 2022. The information from the PSO Profile Form makes it possible, for example, for AHRQ to accurately populate the selection tool on the AHRQ PSO website, provide PSOs with aggregate information at the PSO Annual Meeting, and develop content for the AHRQ National Healthcare Quality and Disparities Report. The PSO Profile Form information should be completed electronically at the PSO Privacy Protection Center website. Please contact firstname.lastname@example.org for information about registering for an account and/or for information about how to submit a hard copy.
Periodically review the PSO Listing Guide
The PSO Listing Guide (PDF, 716 KB) provides helpful information about the PSO listing requirements. It includes a section with self-assessment questions that PSOs may find helpful to review periodically, when preparing for continued listing, or prior to a compliance review by AHRQ (which may be announced or unannounced).
Take advantage of AHRQ's patient safety and quality improvement resources
AHRQ's main website and its Patient Safety and Quality Improvement page contain a wealth of resources that may be of interest to PSOs and the providers with whom they work. These include educational resources and learning opportunities about safety science and strategies for improving patient safety; tools that focus on safety culture, teamwork, and patient engagement, as well as specific clinical topics in patient safety; the Making Healthcare Safer series, which includes reviews and/or updates of the evidence base for many patient safety practices and strategies; and announcements of funding opportunities.
Online subscriptions to the following AHRQ electronic newsletters can help PSOs and providers keep up with the latest patient safety literature and AHRQ resources:
- AHRQ News Now is a weekly newsletter that highlights AHRQ's research and program activities. Sign up at: AHRQ News Now email updates.
- PSNet and WebM&M (Combined resource - sign up for email updates here)
- PSNet features the latest news and essential resources on patient safety, including weekly literature updates, news, tools, and meetings; patient safety primers; and annotated links to important research and other information on patient safety.
- WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of patient safety events, Spotlight Cases that include interactive learning modules available for CME, and Commentaries written by patient safety experts.
Know where to find information about the HIPAA Privacy & Security Rules
The HHS Office for Civil Rights (OCR) interprets and enforces the confidentiality provisions of the Patient Safety Act and Rule as well as the HIPAA Privacy and Security Rules. OCR's website HIPAA for Professionals and its Privacy and Security Listservs may be of interest to PSOs. Since PSOs may receive and use patient safety work product that contains protected health information (PHI), every PSO should determine at the outset when establishing a working relationship with a provider its obligations with respect to HIPAA, if any, and whether it is required by the HIPAA Privacy Rule to enter into a business associate agreement with the provider.