PRMR Final MUC Recommendation Spreadsheet

The term "Excess Days" concerns me as a patient who suffered post-operative harm after my hospital did not provide me the care I needed following my surgery. The use of the term "Excess Days" deeply concerns me because this language is not patient-centric, it implies that the patient does not have individual needs that should be met, needs that may deviate from what is considered standard hospital practices (rationing out our patient care).  A requisite of quality patient care is that it provides care that is individualized and meets the individual person's needs.   

As a lifelong sufferer of asthma (over 50 yrs) and survivor of extended recoveries from respiratory infections, I am imagining myself as a patient who is experiencing pneumonia today. If I had a choice of hospital settings to be treated at (in all truthfulness, this most likely would NOT be the case- patients do not get to choose), I would want to compare data based on the hospitals' past history of providing care that allows a patient to fully recover- the quality of care for a pneumonia-infection provided by each hospital. 

In complete honesty, I do not know how long a patient who was fighting a battle with pneumonia would expect a stay in Acute Care Unit as a part of their care plan.  I am looking at Prognostic Scores and seeing they are waiting until confusion (oxygen deprivation to the brain) and heart function as endpoints to give scores and mortality risks.  What would we think if they sat back and waited until that point to treat our own family member/loved one?  Would that be OK with us? 

While it is nice to know how long it's required of the average patient to recover, we must realize not all patients have the same pair of lungs- eg. I fear that if I acquired a Coronavirus-19 infection, my hospital would treat me just as they do all other patients - not according to how my lungs historically have fared through respiratory infections and asthma attacks.  As a matter of fact, I know that my hospital will not treat me with what I'd need to survive a Coronavirus-19 infection.

This measure could collect valuable data on: 1) whether or not discharge criteria were met by the patient's condition at the time the patient was discharged, 2) what pressures prompt the hospital to practice early discharging  3) whether the patient received patient-centered, quality care prior to their discharge. 

My elderly widow neighbor told me about her experience of her husband, an elderly patient who died at home after his cardiac surgery and bout with pneumonia.  This measure seems to only be concerned with reducing the length of Acute Care stay, I fear it would not be as useful in collecting meaningful data to improve hospital care and safety for patients with pneumonia. 

My friend's son who as a quadriplegic patient was not provided adequate assistance with his daily care, suffered excruciatingly pain from bedsores that developed over the years -until he gave up on his life.  He passed in my friend's arms.  I can only guess that not being provided the care that one needs as a person who is quadriplegic, informs a patient of how little their life means to the world outside of their family.  Living in pain can prove too much- add to this care professionals who were constantly changing his pain medications. 

Bedsores should never happen to any patient in a country as wealthy as ours.

To purposefully keep a patient in pain, instead of addressing their need, should never happen to any patient. In fact, it should be considered medically unethical and deliberate torture.

For some patients there is necessity for prescribing long duration opioids, and should be individually based on their experienced level of pain, on certain medical conditions and after certain medical (and dental) procedures.  Acute bone and nerve pain (eg. multiple myeloma), chronic and terminal conditions, etc. all deserve special consideration.  But even these patients are feeling unintentional back lash from the opioid crisis -not due to any fault of their own- but from physicians' over-prescribing behavior. 

Referral to a pain management clinic and alternative therapies should be included as options along with these prescriptions, but too often they are not -or these options are not available.  Mis-processing of pain experience after brain and/or spinal cord injuries are other considerations so that they do not become chronic conditions.  The US Pain Foundation tells us an estimation of millions of Americans are suffering untreated/ inadequately treated pain. 

Our health professionals should never keep pain relief from us, but looking at our country's current state, we see that for far too many Americans, that's not the case.  So I worry that the effect of this measure may amplify the current trend, making it even more difficult for patients in chronic and severe pain to obtain the means of relief that they need and that is their basic human right to obtain.

After hearing at a IPFCC conference how effective dialysis patient Peer Mentors have been for improving the experience of dialysis patients, I wonder whether the designing of the measure's survey included voices and perspectives of dialysis patient Peer Mentors?  As a person who has firsthand experience with dialysis, a Peer Mentor would have a far greater understanding of what the dialysis patient experience looks like and what their needs might be.  

I wonder whether the patient could be given the option of being accompanied by a Peer Mentor to appointments and whether Peer Support therapy could be offered as another option for their care plan. 

Because the responders are from a vulnerable patient population as terminally ill patients, I also wonder whether the survey questions were written in a trauma-informed manner. 

In addition to requiring the survey be translated into languages other than English, assistance for those with communication challenges should also be provided for their best chance at participating in their own care.  

Older adults have complex needs that are not  currently well served uniformly by hospital care. The Age Friendly Hospital Measure will measure the quality of older adults in a systematic, evidence-based fashion, providing a framework for quality of care measurement and improvement ensure optimal care for older adults. 

Equitable Patient Care includes more than just the results and outcomes from patient care.  It also includes the patient experience:  all too often I watch videos of young Black women talking about their patient experience in which their complaint was ignored, trivialized and went untreated for years, even decades causing the development of more health issues as a result.  I am wondering whether this measure collects data on this sadly all too common health equity issue? 

Does this measure first educate the patient of what standard medical practice should ideally look like for a patient with their medical condition? (eg. provide information on which health professionals are commonly seen, which care professionals are patients typically referred to treat certain symptoms)  Basically, I am asking whether patient responders will have a full understanding -through transparency of what a care plan should look like - in order to make an informed comparison with the care they received- enough to judge- and confidently answer whether or not they received "quality" patient care?  Using my experience as a brain injury patient, it wasn't until after I read how BI care should look from physician training modules on care management, that I realized how few of my symptoms were treated, supports and services were provided that I needed.   By not being transparent about our care plan and not informing us of what we should expect, health care providers are relying on our ignorance of what quality care should look like when we grade them in surveys.

Other issues our minority patients may experience include: the patient received their health care but was also the recipient of a micro-aggression or other negative interaction with a health professional, resulting in their distrust of the system and avoidance of seeking further healthcare.  Does this measure collect data that would capture these kinds of patient perspectives and experiences? 

I recommend adding patient self-report or comment elements to the survey used in this measure;  otherwise, we may have folks with vested interest stacking the numbers with simple Y/N close-ended questions that favor their health institution.  

Dear Centers for Medicare & Medicaid Services,

 
My wife Joan died from a medical error in 2017.  My family and I were left to handle the consequences on our own.   As a result I began investigating and was appalled at the size and scope of this issue.  Although patient safety organizations have developed methodologies and tools that provide open communication and transparency as well as support to those harmed, many hospitals still cling to the traditional ‘Deny and Defend’ policies as dictated by their legal and risk management departments.   

This is why I am so glad that CMS is directly addressing this tragic issue.  It will require all healthcare executives and boards to consider their options and hopefully comply.   Due to the current lack of transparency, even after 6 years I can’t be sure that the issue that took Joan from us hasn’t been repeated somewhere.  Even more disturbing to me is that it most likely occurred somewhere before our tragedy, when transparency would have saved her life. 

I recognize and appreciate CMS for developing a Measures Under Consideration list prioritizing patient safety and health equity. Harm, bias and discrimination are problems affecting everyone—patients, families, clinicians—anyone who needs or provides care. It seems that there are constant studies bringing the consequence of these problems into harsh light. Thank you for offering the structural measures as method to solve these problems.

2024 is the 25^th Anniversary of To Err is Human, the National Academy of Sciences call to improve patient safety. As the signors of this letter know, we are far from reaching the patient safety goals defined in the report. The slow progress toward greater safety and equity, make CMS leadership extremely important and powerful. As Americans, we expect our health systems to be safe for everyone, regardless of patient demographics that too often, lead to disparate patient outcomes.

We appreciate the opportunity to share our own experiences and those of our loved ones, as we are often driven to advocacy because the health care system has harmed us. We are pleased to know our experiences and input are valued.

We strongly support MUC2023-188: Patient Safety Structural Measure without delay as it asks hospital leaders to publicly attest to their organization’s establishment of best practices in following domains: 

1) Leadership Commitment

2) Strategy & Policy

3) Culture of Safety & Learning

4) Accountability & Transparency

5) Patient & Family Engagement. 

These measure have the potential to improve patient safety and reduce health inequities. Public reporting by hospital leaders will help Americans identify hospitals that have implemented patient safety and health equity best practices and those that have not. Implementing these measures without delay will allow data to be analyzed and used for broad improvements. 

There are several best practice guides readily available to hospitals to aid in complying with the proposed structural measures. New tools will always be welcomed, but there is no reason to wait for their development. The need for improvement is immediate so I urge CMS to implement MUC2023-188: Patient Safety Structural Measure as soon as possible, before other families suffer as mine did.  

Sincerely,

John Adams

It is very important for hospital systems to collect and disclose quality metrics for older adults. This will help assess the quality of care for a vulnerable patient population where cognitive, physical and socioeconomic factors could be a barrier for equitable access. 

See attached file

The American Medical Association (AMA) appreciates the opportunity to comment on the final 2023-2024 Pre-Rulemaking Measure Review (PRMR) recommendations. While we found the Recommendation Group meetings to be well facilitated and the discussion by the members clearly identified the areas of support and/or concern, we do not believe that the rationales adequately summarize what was at times a lengthy discussion. We are particularly concerned that for those measures in which the Recommendation Group was unable to reach consensus, any potential conditions such as reporting a cost measure at the group level only are not reflected nor do the rationales provide enough detail on why the group was unable to agree on a final recommendation category. We believe that additional information, particularly for the measures where consensus was not reached, is needed. 

The American Medical Association (AMA) appreciates the opportunity to comment on the final 2023-2024 Pre-Rulemaking Measure Review (PRMR) recommendations. While we found the Recommendation Group meetings to be well facilitated and the discussion by the members clearly identified the areas of support and/or concern, we do not believe that the rationales adequately summarize what was at times a lengthy discussion. We are particularly concerned that for those measures in which the Recommendation Group was unable to reach consensus, any potential conditions such as reporting a cost measure at the group level only are not reflected nor do the rationales provide enough detail on why the group was unable to agree on a final recommendation category. We believe that additional information, particularly for the measures where consensus was not reached, is needed. 

Please see attached letter from ONS on the measure, Appropriate Germline Testing for Ovarian Cancer Patients. 

To whom it may concern,

I want to support the inclusion of patient safety and health equity measures in the FY 2025 Medicare Proposed Rule and I want to have CMS implement this without delay, starting in FY 2025.

Respectfully,

Mary Herold 

I am an adult-gero acute care Clinical Nurse Specialist by education and experience. I practiced in this role for the past 12 years in an adult emergency department. As a liaison for the Geriatric Committee at the Emergency Nurses Association (ENA), we are responsible for developing geriatric education specific to emergency nurses and often use the Age-Friendly 4Ms framework in our content so that we are following best practices for geriatric emergency care. The older adult population is out-pacing that of trauma and pediatric patients in the emergency care setting and requires a model/measure to guide nursing practice and improve patient outcomes. The age-friendly measure for older adults is important to the ENA and our members as we are the primary organization for ensuring that emergency nurses are well-equipped with knowledge to assist them with the most current information to provide appropriate care for the older adult population. Emergency department patient boarding is continually increasing and many of these patients are from the geriatric population. The Age-Friendly measure coupled with geriatric ED accreditation will provide specific geriatric emergency care, improve assessment and evaluation skills, and enhance the timely identification of high-risk issues within this population. This is applicable to the ED in that we perform screenings to mitigate delirium, falls, 30-day readmission, and ED revisits. The age-friendly process starts the minute a geriatric patient enters the ED doors via ambulatory, caregivers, or emergency medical services. 

I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay, because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices.

Concerning the conditions articulated

1. The best way to generate additional data across the 5 PSSM domains is to implement the PSSM as soon as possible so that attestation data about what hospitals are doing can be gathered, analyzed, and used in improvement work.
2.  There currently exists several best practice implementation guides readily available to hospitals, including Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template, the Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool, the CANDOR (Communication and Optimal Resolution) Toolkit, and the World Health Organization’s Global Patient Safety Action Plan, among others. While we welcome additional tools, there is no reason to wait for their development.

I am also  grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process

On behalf of our nearly 40,000 members, the American College of Emergency Physicians (ACEP) appreciates the opportunity to comment on the 2024 Hospital Measure Under Consideration Final Recommendations. Our comments pertain specifically to MUC023-196, the Age Friendly Hospital Measure, which reached a 73.68 percent vote for recommendation.   Please see the attached for our full comments.

As a geriatric medicine physician, I support the Age Friendly Hospital Measure as a means to standardize the assessment of the care of older hospitalized adults and to guide quality improvement initiatives within acute care hospitals. 

Hospitals are increasingly faced with older patients who have complex medical, physiological, and psychosocial needs that are often inadequately addressed by the current healthcare infrastructure. The Age Friendly Hospital measure presents a quality program that addresses the current public health challenge facing the aging population—elements of responsibility, accountability, and data-driven improvement are programmatically applied for this population. Using this structure breaks down care siloes to create comprehensive care processes across the full spectrum of geriatric care.

"During this hospital stay, how often were doctors, nurses, and other hospital staff informed and up to date about your care?"

>>>  This question is shallow, close ended, poorly worded (by asking "how often") and only allows the patient to respond in the form of  multiple choice answers.  It is unrealistic to expect that patients know what an "informed" health professional should look like or if our medical experts are "winging it". Often the patient and families themselves are not informed about their own care plan, what should be happening and chronologically when -unless they had undergone the same type of hospital care before- let alone know whether or not their physician is up-to-date with current practice standards.  The patient must themselves be informed about what they could ideally receive in order to discern whether or not they received timely, adequate, effective, individualized, coordinated care to meet their patient needs: quality patient care. 

The question should provide space for the patient to comment and provide meaningful information that could help improve quality patient care and safety -and also so they can better participate in their own care (eg. Were your doctors and nurses informed and up to date about your care? Please explain why or why you do not think so.)

"During this hospital stay, how often did doctors, nurses, and other hospital staff work well together to care for you?"

>>> Wording of this question "how often" asks for the patient's perspective on what is outside of their knowledge.  Patients would only be able to observe the communications that go on in front of them, like during bedside huddles.  It is only when things do not run smoothly, if orders were not placed, when results are slow to come back etc., only then would we be alerted that communications are not happening as they should behind the scenes.  Only then we would perceive that communications were poor.

Again, the patient needs to be educated about what quality care would look like for a patient like them in order to answer this question in an informed way.  It's widely accepted that in general our care is not transparent. It makes a person wonder what are patients missing out on? 

This survey is an opportunity to welcome engagement of the patient in their own care by asking them directly whether communications were good between hospital staff and if not, provide space for them to elaborate about their experience during their care.  A reworded question would provide more meaningful information and valuable data for quality improvement and patient safety. 

"Did doctors, nurses, or other hospital staff work with you and your family or caregiver in making plans for your care after you left the hospital?" 

>>> The content of the "work" (with you and your family) matters greatly to the patient and family;    What was discussed may or may not have been adequate, or focused on their physical condition, to properly prepare the patient and family for the return home after their hospitalization.  So Yes, they may have "worked " with the patient, but No, it was not enough to prepare them so they were not placed in danger of causing a house fire, falling down stairs, overdoing it / shoveling snow, among other possible hazards when returning to their home. 

My experience leaving the hospital: zero plans were made.  I wonder how many other patients would say the same.  As Patient Advisor at my hospital, I did see a significant portion of their returned HCAHPS survey patient comments discussed similar complaints of too early a release.  They released me from the hospital despite the fact I did not meet criteria:  I was experiencing a horrific level of pain, was vomiting and extremely dizzy.  I found out later that hospitals are making a policy change: formerly inpatient surgeries are now categorized as outpatient surgeries.¹  So the system is sending home patients with complex health issues beyond just wound care- mine included vision impairments, disorientation, dizziness, hyper-sensation, mental health issues from a head injury moderate traumatic brain injury and skull fracture repairs.  We need much more supports and services than what they "plan" for us. 

This question only asks to check the box (Y/N); it does not allow the patient opportunity to provide valuable information and insights on gaps in care processes and failures of the system.

REFERENCE:

1)  THE 2023 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS. (Introduction) https://www.cms.gov/oact/tr/2023

Close ended questions force the patient to answer with responses that hold less meaning and do not allow for subtleties and nuances of the patient experience (eg. one out of their 3 doctors interrupted the patient's sleep- so how should they answer- Y/N, so it's all or none?).  This measure could be simplified with fewer questions and could provide room for the patient to discuss any issues:  eg. Were you able to rest?  If no, please comment why and what could be improved. 

Reading too many questions about performance items on the survey seemed to me like an attempt to distract me or cause fatigue as a patient (as someone with a traumatic brain injury and in severe pain), like a design to keep me from providing feedback on real quality and safety issues that mattered to me and that would help the health institution pinpoint gaps or failures in care helping to improve quality of patient care. 

Will this measure lead to a greater focus on the importance of the patient's uninterrupted sleep - to regain their strength- rather than prioritization of staff schedules and routines? 

I am concerned that this measure essentially asks the patient to check boxes, asks for minimal input from patients on the quality of their care.  

"During this hospital stay, when you asked for help right away, how often did you get help as soon as you needed?"

"When you asked for help" does not take into account patient experiences like when one awakes from anesthesia and feels excruciating pain but can not yet communicate- this patient experience is excluded from being reported due to the survey asking too specific a question. 

"How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?"

By limiting the patient's response to these questions with multiple choice answers, this sub-measure misses the opportunity to collect more meaningful data from patients on how responsive staff are to meet other urgent needs of patients to help improve quality of care and patient safety.

The timing of these patient communications is critical.  Effective communication of critical health information for understanding can be complicated:  the health professionals may have performed their best at communicating this information, but the patient and family may not have been in an emotional/ psychological state to listen, cognitively process the info and commit it to memory- to learn new information.  The patient and family may have been going through a traumatic experience and unable to learn new information during their stay or at discharge when many things are happening at once.  The patient may be on medications to make them drowsy and inattentive, and family may be so exhausted they too may not have in a place to learn these important communications.  I am wondering whether data from this measure might lead to alternatives ways and timing to unload this information on patients, instead of just as they are about to leave. 

How the communications are provided is critical.  Brain Injury survivors for instance are not provided with communication accommodations - we are verbally given information in a rushed manner despite our obvious impaired cognitive functioning. 

Discharge can be a busy, distracting, confusing time when it is not the best or not suitable time or place to effectively communicate.  It may be the necessary to provide alternatives, like a video recording to be replayed later, to communicating care information at another time.  Written communications can be difficult for a patient suffering vision impairments as a result of their injury, other communication challenges need to be taken into account and provided accommodations, too.

We need to have a good understanding exactly who is being released from our hospitals.  Our national health system does not provide patient-centered care when it prioritizes the cutting of costs and optimization of patient flow efficiency - to the point where we are now performing inpatient surgeries as outpatient surgeries.¹  We watch televised news reports showing patients- still in their hospital gowns- being escorted by hospital security and dumped on to cold street corners (Louisville, KY).²  Clearly these patients were not ready to be released home, but a medical decision was made that they were.  We are sending home patients with complex health needs;  these needs require so much information on how to address them, it's very likely it cannot all be communicated within the 15 minutes that health professionals are allotted to perform this task (that was certainly what it seemed like- if even that long).  

These trends should serve as a warning to the American Public, telling us what to expect from our hospitals when we enter their doors;  what they accept as their responsibility to care for a patient and for deciding when they are ready to leave for home. 

Our health institutions do not provide patient-centered care; we should instead say we receive "business model-driven care", or care that fails to offer us respect and dignity as a human being. 

By limiting the patient's response with a Y/N question, this sub-measure misses the opportunity to collect more meaningful data from patients on how well staff communicate after hospital stay patient education and more insightful data about how well this communication meets the needs of patients- in order to help improve quality of care and patient safety.

REFERENCES:

1) The 2023 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.  (Introduction)  https://www.cms.gov/oact/tr/2023

2)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (7 min video) https://youtu.be/rFJsFdgMkYE?si=AIIFdFtjsB6AItDk

Performing a screening for SDOH needs and responding to the results of screening are two separate issues. I was screened several times after sustaining a head injury, double vision and moderate TBI only one was performed with cognitive communication accommodations that I needed - such as giving me time that I needed to process the question and recall information to answer, verification/ collaboration of the accuracy of my responses, etc.  The screening process is rushed, it is not performed in a trauma-informed manner and I felt that my responses were at times trivialized and down-played (causing me harm, worsening of conditions later on).  Marginalized and minority patient populations who screen positive for SDOH have to first deal with racism, paternalism, ableism, sexism, sizeism, elitism of health professionals who screen them in order to receive the care they need.

Will this measure take these barriers to care into consideration and help guarantee the quality of the performance of the patient screening for SDOH?

Patients are too often kept in the dark about what their own care plan looks like and what is happening to them -instead of together, with them: patients have no idea which medical decisions are being made without their knowledge or input -instead of participating in shared decision making.  Patients need more transparency about what to expect as far as referrals, what supports and services are available to them that would come from their care professionals. 

Will this measure help ensure the transparency of the patient's care plan around gaining SDOH-based  supports and services?  Will this measure ensure that patients who screen positive for SDOH are engaged in their own care, and empowered with shared information and choices? 

Will the data collected from this measure help improve the quality of care and patient safety of patients that undergo screening for SDOH?

Patient self-reports of their initial experience of pain and of their pain experience after intervention was provided, 

are absolutely essential for quality pain management care and safety of our hospice patients.  

No person should have to live in pain.  

The US Health System has a long way to go before it can say it provides patient-centered care and utilizes patient-centered practices. 

This measure looks at assessment and reassessment of a patient-reported experienced non-pain symptom.  Because hospice patients are from an especially vulnerable patient population, I am concerned about the patient's safety during this process- would the patient feel pressure to respond positively to the assessment and reassessment questions out of fear of retribution (eg. a care professional who may take offense at a negative response and threatens the patient by not providing the patient care)?  

Will the quality of the health professional's performance of the screening will be analyzed as a part of this measure?  Oftentimes screening is done by a health professional who is in a rush- because our system prioritizes efficiency of patient flow, at times over the communication needs of certain patient populations.  Screening may/ may not be performed in a trauma-informed manner, so the patient may not feel safe or comfortable enough to disclose intimately personal information.  As someone who was screened after a head injury, suffering both sensory and cognitive impairments, I am unsure whether I even gave the correct answers to screening questions.  It felt like the screening process was done to simply for my care professionals to check off boxes; the screening results did not seem to alert my physicians that I required additional assistance and that they should refer to care coordinators who could connect me to services I needed.  A study, analyzed 2019 Medicare CCM and TCM claims, and found that very few Medicare beneficiaries are receiving the services that are available and they are eligible for (only 4% CCM beneficiaries and 17.9% TCM beneficiaries).¹  Simply performing the screen does not ensure quality patient care is actually delivered.  Will this measure look at whether positive screen results elicit responses (care management) from our health providers? 

REFERENCE:

1)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services. https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf

I am concerned about what "initiation and engagement" would look like to the patient.  1) I hope that communications would be done in a trauma-informed manner. 2) I hope that the patient would have a number of available treatments as options to choose from and that the process would seem less like "compliance" with a health professional's choice of treatment that does not suit the individual.  Will this measure ensure their care is performed in a respectful manner that is transparent, individualized, patient-centered and encourages shared decision making?   Will this measure include a patient self-report component to allow for continuous quality improvement and patient safety data collection? 

Will this measure recommend assessing elderly patients for possible cognitive communication skill impairments? 

When a patient from a vulnerable population, such as an elderly person, enters a health institution, it is important that they are immediately recognized as such; immediate assessment of their cognitive communication ability should take place and staff must provide for their communication needs through cognitive communication-informed assistance and accommodations, eg. by speaking to them more slowly, to ensure they are engaged and involved in their care.  

A quality measure for facility commitment to  Health Equity should elicit descriptive patient feedback about their care.  Patients from our various minority groups face racism, ableism, sexism, sizeism, paternalism, elitism, in addition to other provider biases which are all known as barriers to receiving care and are known as patient safety factors- issues that no one will openly admit are deeply embedded within our health institutions,¹ nor assess for in their quality data collection.  For these reasons it is essential that this measure incorporate input from individual patient experiences as patient safety and quality care data.  What we have is an unethical scenario, the fox guarding the henhouse, which is perpetuated by hidden curricula² -a situation that we need to end.       

As a brain injury (BI) survivor, it is my perspective that we are far from reaching Health Equity.  Our health system leaves patients isolated and struggling on our own to find the care that we need.  We suffer from issues such as anosognosia, communication impairments, sensory perception impairments, mental health issues etc. which make obtaining care even more difficult when there is no real standard practice for our care management and a lack of willingness to provide us care (due to our high cost to the system).³  When we discover BI survivor peer support groups, we find survivors like ourselves who had been through similar life struggles and who collectively hold a treasure trove of BI care knowledge, insights on recovery, valuable information that aids us in finding our healing path.  In contrast, we are told by our  doctors that peer support is not appropriate or "just a bunch of whiners and complainers".  This was just one instance among many other excuses we hear for not providing the supports and services that we need ("I didn't know you needed that" "if I gave you that referral, I'd have to give one to everyone", "I can't help you" "you are one in a million"...)  I made a list of all the specialists/ therapists that my primary care and physiatrist doctors referred me to and compared it to another list of specialists/ therapists that my friends, peers or myself recommended I see and the latter was twice as long as the former- I call it my DIY BI care (includes concussion evaluation, neuropsychological evaluation, psychiatric evaluation for PTSD). This is in a nutshell what brain injury survivors can look forward to upon entering our US health system. 

Immediately after my accident and the first 2 facial fracture repair surgeries, my doctors provided me with a barrage of physiatrist sessions: they stared at me curled up in the exam room, crying- did not provide me the referrals I needed for pain management, transportation (I was medically restricted from driving), mental health care... but did provide me a barrage of OT appointments that left me wondering when they would get to the issues that I was facing (a cookie cutter approach to BI care, one size fits all).  I began to think they were setting up all these appointments just to make money off of me- I certainly was not benefitting from them.  In fact, it was stressful for me at that time to attend them all when I was sleeping through 75% of my day the first month and a half of recovery, I had to find a ride or ended up walking 45 minutes to the bus stop to get there (with double vision, sidewalk cracks were Xs, not parallel lines, on pain meds, dizzy and disoriented from my moderate TBI- at risk for a fall and second concussion syndrome).  It wasn't until a year and a half later that I discovered they could have connected me to a social worker or community health worker to get help with my paperwork for disability and insurance billing was a bear, my tax returns which had to be re-done four years in a row, learning accommodations for my return to school which was a failure...  I ask from the perspective of someone who suffered mentally and physically from gross medical neglect- a common theme with my BI survivor peers- whether this health system is truly serious about Health Equity and how are we going to fix it to make it so.  

REFERENCES:

1)  When Patients and Their Families Feel Like Hostages to Health Care.  2017.  https://pubmed.ncbi.nlm.nih.gov/28843434/

2)  The Hidden Curricula of Medical Education: A Scoping Review.  (2018) https://journals.lww.com/academicmedicine/fulltext/2018/04000/the_hidden_curricula_of_medical_education__a.48.aspx

3)  H.R. 1976 - Medicare for All Act of 2021. ("high-cost patient" label twice appears in Legislative Text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

On behalf of Pfizer, I am pleased to respond to the Centers for Medicare & Medicaid Services (CMS) request for public comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results and recommendations. Specifically, in the attached file, we write in response to the recommendation of “consensus not reached” for use of the MUC2023-164 Adult COVID-19 Vaccination Status measure in the Merit-based Incentive Payment System (MIPS). 

AOTA thanks CMS for the opportunity to comment on the finalized recommendations of the PRMR committee in regards to the measures under consideration. We have provided additional comment regarding MUC2023-209 Rheumatoid Arthritis in the attached letter. 

I am Nicole Cable, and I am submitting this Public Comment as a patient who has personally experienced the impact of a hospital-acquired infection. Patient safety is a critical aspect of healthcare.

I applaud CMS for developing a Measures Under Consideration list prioritizing patient safety and health equity.  Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded issues in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable. An alarming new study also finds that 795,000 people die annually or are harmed due to missed or delayed diagnoses or the failure to communicate an accurate diagnosis.

This year, we’ll reach the 25th Anniversary of To Err is Human, the National Academy of Sciences call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity paramount. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

We are also grateful that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. We are pleased to know our experience matters and that our input was heard.

Domain 1: Equity as a Strategic Priority

Health Equity as a goal actually runs counter to the objectives of our capitalist-based health system.  Our health system follows a business-model narrative that we must "cut costs" and "make care processes more efficient"; internal pressure is placed on physicians to not "go over budget" with the care they provide.  It seems to be "a feature, not a bug" with this approach to providing health care so that: 

1) patients like me are labeled as "high-cost patients" and are provided care that is less than what is required to meet our needs - without the respect and dignity that we deserve; 

2) the system prioritizes these business-driven practices over its mission to "serve the health care needs of the public"; 

3) these business-driven practices fail patients and are putting us at risk of medical harm and death; ¹

4) our capitalist-based system ensures its own perpetuation by designing and developing its own Quality Measures that are permissive of (1-3) and that give health institutions a pass even when they should be held accountable for their dereliction of duty; 

4) today in America, it is more prevalent for patients to be underserved than receiving the care that they need; 

5) patients are not receiving the value of patient care that our national care programs, private insurance and copayments should have paid for and covered;   

6) yet we observe corporate interests and hospital upper-echelon administrators hauling in record profits and salaries- essentially off of the backs of the public.  

In summary, it appears the strategy of our health entities is to exploit patients who are seeking a basic human need and not to give them back in value what had been paid for.  From the patient perspective, especially those of us "frequent flyers" with chronic and complex conditions, it seems our system's strategic priority aims closer to medical negligence and harm than towards achieving Health Equity.

In considering what Health Equity should look like, I recommend reviewing The Joint Commission's (2016) A Roadmap for Hospitals: Advancing Effective Communication, Cultural Competence and Patient- and Family-Centered Care.²  At eight years after publishing this roadmap, our health care system does not even approach the recommendations the Roadmap has set up- the COVID pandemic exposed to us that we lack the resources, staff, facilities, beds... capacity to meet our patient volumes, we continue to fail patients, especially patients with greater or different needs. 

Domains 2 , 3: Data Collection and Analysis

When serving on my regional hospital's Quality and Patient Safety Committee, I asked tough questions like does the safety data we're discussing reflect the patient's reality? The nurse supervisor candidly responded to me: no, it's just the tip of the iceberg.  Events are underreported.  Across our nation we see underfunding of patient advocacy departments, leading to overworked staff and cases piling up- which says to us we are not serious about accountability, Patient Safety and Quality Improvement, in general. If we were seriously committed to addressing patient safety issues and improving quality of our care, it would be evident by more investment of institution budgets in these areas of data collection and the hiring of sufficient staff to analyze it.  Will this measure take this into consideration health institution budget allotments in these areas to assess health entities' commitment to Health Equity?

Also we want to push for the inclusion of the patient voice in patient complaint processes, root cause analyses, task force processes and hospital investigations when they are being conducted.  Leaving out the patient voice often means the importance and urgency are diluted and patient complaints are misinterpreted. 

On training for staff to deliver culturally sensitive practices, we want to push for patient voices to be included in the assessment of performance of staff who were trained for cultural sensitivity.  It is one thing to check that box for the training but another to have learned from the training enough to practice their learning with patients. 

Domain 4: Quality Improvement

During the eight years of service on my hospital's Patient Advisory Council, I am not seeing strong effort being made toward real effective change- it seems the hospital does not prioritize improving the items that most need to change and that real effective change in these areas would be "costly" for them to implement.  Instead, they continue to address "low hanging fruit" which has less impact on quality care while pushing to the backburner what could end the harm of many patients.   

My grandfather and father practiced as small town physicians; both received holiday food gifts from their patients as a show of appreciation for the patient care that they received. How many of us today feel the same about our own care providers- enough to gift them something?  Also, I don't recall hearing nowhere near as many people becoming medically bankrupt from their illness, do you?  Our past history holds evidence this nation once provided patients much better quality care; with the amount of wealth and resources that our country embodies, there is no reason we couldn't do it once again. 

Domain 5 Leadership Engagement:  

An example of what Health Equity (HE) does not mean: when our medical leaders publicly speak saying that we've accomplished our goals.  HE actually means what patients from our most vulnerable, our ability-challenged, marginalized and minority populations have to say about the need to improve their patient care experiences.  While attending my regional hospital's 2022 Health Equity Summit, our hospital leaders proclaimed to over 550 attendees that they provide "quality patient care" and "patient-centered care", so someone in the room would get the impression that we are accomplishing these goals.  That speech was given in direct contrast to the patient experience stories later told by communications-challenged patients on a discussion panel, speaking on how their different abilities proved to be major challenges and barriers to receiving the quality of care that they needed and deserved. Two opposing perspectives coming from our leaders of our health system and our users of our system.  Who should we listen to for leadership in defining the problems we face and for finding effective solutions?  Who should we hold accountable for the current direction we are all headed in?

Contrary to what our leaders seem to believe, we cannot manage our way out of a deficient and defunded health system by changing payment programs, cutting costs and making health processes more efficient.  The health system is not a factory and we are not gadgets being produced on a production line.  In Vermont, we lack the number of Case Managers and acute psychiatric beds that Vermonters need, yet we have F-35 fighter jets roaring overhead on nearly a daily basis; at least to me this provides evidence telling us our priorities are not in the order they need to be.  We must face the fact that our health system is not accomplishing its mission, it is leaving our most vulnerable people behind, excluding our fellow Americans from the system and from obtaining the patient care they need.

I truly believe that if our medical and political leaders understood:

• how we could make our federal government work for us to help us find solutions to our current health system problems,³ 
• how our federal government as a sovereign currency issuer fiscally operates- without any cost to Americans (creation of US Dollars requires only clicks on a keyboard),⁴ 
• how our government could easily fund any program passed by Congress,⁵ 
• that our federal government could provide sufficient funding to cover our health care needs and expenses, just as it does our ever-increasing US Military budget,^6,7 

THEN perhaps we would understand: 

• that our system could provide 335 million Americans much higher quality patient care- which is exactly what over three fourths of the public wants.  
• that it is a fallacy to continue thinking provision of high quality health care is not fiscally sustainable.  
• that we could rebuild the system's capacity to serve our patient volumes instead of continuing to experience national shortages. 

If we all thought over the evidence rationally and realigned our goals to the best interests of the American People, would  unite to ensure our US government fulfills its responsibility to provide for the general Welfare of its public.⁸ 

REFERENCES:

1)  The third-leading cause of death in US most doctors don't want you to know about.  (2018) https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html#:~:text=According%20to%20a%20recent%20study,after%20heart%20disease%20and%20cancer.

2)  A Roadmap for Hospitals: Advancing Effective Communication, Cultural Competence and Patient- and Family-Centered Care.  (2010, was previously free online, but now requires membership to access) https://healthbridges.info/roadmap-for-hospitals/

3) Dr. Stephanie Kelton Economics Professor, Stony Brook Univ. and author The Deficit Myth discusses how our federal government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=hn6q8f8-0JfvG34W

4) Former Federal Reserve Chairman Ben Bernanke discusses how the government fiscally operates (2020, 1 min video) https://youtu.be/yDQOIkPwgvI?si=9PYlZOcgFe-1Sg8n

5) Federal Reserve Chairman Alan Greenspan responds to Congressman: "There is nothing to prevent the government from creating as much money as it wants." (2005, 1 min video) https://youtu.be/DNCZHAQnfGU?si=6qhCvDOyKksN7CpZ

6) Economist Dr. L. Randall Wray while discussing his book, Making Money Work for Us, answers my question about what health care funding legislation should look like (2023, go to 3:01:00 of video):  https://www.youtube.com/watch?v=nt_nBTRdQiQ&t=10879s 

7) Chair Yarmuth Joins CSPAN to Discuss funding of the President's Budget. (2021, 26 minutes video) https://youtu.be/RvlpF6FZkLI?si=Qp8FcdmqRvkOVsIX

8) Stop the Charade: The Federal Budget Is Its Own 'Debt-Ceiling'. (2023) https://www.forbes.com/sites/rhockett/2023/01/19/stop-the-charade-the-federal-budget-is-its-own-debt-ceiling/?sh=600b55597bc9

Our nation does not provide nearly enough supports and services for our mental health patients. Will this measure help to assess the level of mental health needs that goes unmet, where the system deficiencies and failures occur in mental health patients' care processes?   

Questions asked are narrow and in a closed (Y/N) form.  Meaningful data used for continuous quality improvement comes from asking open ended questions to elicit more detailed information and valuable insight from the respondent.  Unlike a routine teeth cleaning, this care delivery process is about providing quality care for a family member during their final living days.  Patient- and Family-Centered Care should mean showing dignity and respect to the patient and family by welcoming their input and allowing them the opportunity to provide feedback beyond a Y/N or multiple choice response.  

Again, the questions asked are too narrow, asking about communications that are one directional.  Unlike for a routine procedure, like a teeth cleaning, this crucial care delivery process is about providing quality care for a family member during their final living days.  Patient experience encompasses more than unidirectional communications.  For more insightful and informative data collection to help improve quality of care and patient safety, the patient and family should be given the opportunity to provide more in depth responses than just multiple choice answers.   

Again, this is a closed form (Y/N) question that will not use this crucial opportunity to provide meaningful information and valuable insight on the patient experience of hospice care nor how to improve the care of hospice patients.  Unlike a routine teeth cleaning, this care delivery process is about providing quality care for a family member during their final living days.  Patient- and family-centered care means to provide care that shows dignity and respect for the patient and family; asking for a simple Y/N response diminishes the importance of the patient and family voice in the care setting.  For more insightful and informative data collection to help improve quality of care and patient safety, the patient and family should be given the opportunity to more fully participate in their own care by allowing them to give more in-depth responses than a Y/N answer.   

See the attached comments from the American Academy of Otolaryngology - Head and Neck Surgery. We appreciate the opportunity to comment and welcome any questions to [email protected]. 

Please find comments attached on behalf of the American Academy of Otolaryngology - Head and Neck Surgery. We appreciate the opportunity to comment and welcome any questions at [email protected]

My concern for this measure is whether it would include the patient and family feedback and engagement in the processes of reporting and data collection for continuous improvement of quality care and patient safety.  

My concern for this measure is whether it would include the patient and family feedback and engagement in the processes of reporting and data collection for continuous improvement of quality care and patient safety.  

Analysis of 2019 Medicare services data showed that just 4.0% of beneficiaries potentially eligible for CCM received any CCM services.  Of all beneficiaries with acute care discharges eligible for TCM, only 17.9 percent received TCM services.¹  Patients who are denied the healthcare that they need are being denied a basic human right. At what point - how many lives must be unnecessarily harmed?  how many deaths will it take before we implement real effective change:  move to a national health program that works for all of us? 

REFERENCE:

1)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services. (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf

West Health is a family of nonprofit, nonpartisan organizations that combines applied medical research, policy analysis and grantmaking to improve care, lower costs and enhance the aging experience for all Americans. In our daily work, we collaborate with researchers, patients, healthcare providers and health insurers to study, develop and advance scalable, sustainable and more affordable healthcare delivery models that enable individuals to successfully age in place with optimal well-being.

We are grateful for the opportunity to support MUC2023-196 Age Friendly Hospital Measure incorporation into the 2025 Hospital Inpatient Prospective Payment Systems (IPPS) proposed rule within the Hospital Inpatient Quality Reporting (IQR) Program. West Health commends the Centers for Medicare & Medicaid Services (CMS) for this important initial step to encourage hospitals to provide high-value care for older patients. 

Inclusion of MUC2023-196 Age Friendly Hospital Measure into the Hospital IQR Program aligns with West Health’s mission to enable access to value-based health services that preserve and protect dignity, quality of life, and independence for older adults. MUC2023-196 Age Friendly Hospital Measure will require acute care hospitals to attest whether they meet specifications outlined within five mission-aligned domains: 

Domain 1- Eliciting Patient Healthcare Goals

Domain 2- Responsible Medication Management

Domain 3- Frailty Screening and Intervention

Domain 4- Social Vulnerability

Domain 5- Age Friendly Care Leadership

The components within each domain are clinical best practice with real-world evidence demonstrating improved care for older adults and reduced healthcare spending.

Our medical research organization, the West Health Institute (WHI), conducts collaborative projects with healthcare organizations across the country. Our work with these partners exclusively focuses on the older adult population, providing us with firsthand knowledge about the care of Medicare beneficiaries nationwide. We have seen programs with the types of interventions advocated for in MUC2023-196 Age Friendly Hospital Measure positively impact patients and have witnessed that many of the structural elements and processes outlined within the components of this measure are already in place in hospitals across the country. In particular, our collaborations exploring implementation of the Geriatric Emergency Department model demonstrate that formalizing a best practice, such as screening for delirium, into hospital protocol ensures clinicians are allocated sufficient time and resources to assess patients’ needs and provide the appropriate level of care in response.

The expectations outlined within MUC2023-196 Age Friendly Hospital Measure will improve quality and should be in place to ensure value-based care for older adults. Medicare beneficiaries have a right to know which hospitals are practicing according to the highest standards of care. The protocols outlined within the five domains are evidence-based best practice, yet implementation is currently hospital dependent. Adoption of MUC2023-196 Age Friendly Hospital Measure as part of the Hospital IQR Program will encourage hospitals to implement the programmatic structure and processes required to meet these domains through policies and protocols, thereby incentivizing the domain components to become common practice. Public reporting of this measure on CMS’ Care Compare website will ensure consumers have access to information to select high-quality care.

Evidence shows that in the field of healthcare, “what gets measured, gets done.” MUC2023-196 Age Friendly Hospital Measure attestation should result in investments to improve quality across the five domains. The national heterogeneity of practice regarding domain components is precisely why an attestation-based structural measure is an appropriate design. Many of the best-in-class health systems we partner with are already successfully doing much of this work across a variety of settings, from rural and safety-net facilities to large academic medical centers. Incorporation of MUC2023-196 Age Friendly Hospital Measure into the Hospital IQR Program will encourage these practices to be adopted across all health systems, not just those performing at the highest level, while simultaneously allowing sufficient flexibility for hospitals to meet the measure requirements. 

Please see attached letter for associated references.

Our US towns and communities, just like our health institutions, are currently not able to address urgent public needs like housing and food security, let alone health care, education and other basic human needs.  With all of our shortages and deficiencies, we have great need to rebuild local resources, care networks and facilities, hire staffing...  we lack the capacity to meet and fulfill the public's needs because we lack the funds.  In a country as wealthy as ours it is shameful that we are left struggling to survive - no where near able to thrive.  It is wonderful that CMS is working hard to collect data on SDOH, but we are wondering when our health leaders will call on Congress to invest in those community and health system deficiencies they will find (that we patients already know about)? 

It is my argument that we need to conduct nationwide needs assessments for all of our communities and for all of our patients.  Until we gain a full understanding of the actual levels of community and patient needs, we will not be able to offer an accurate estimate of the amount of funding we need in order to train and hire the numbers of health and social service professionals to meet and serve the actual level of needs of our public.  It is unfortunate that the needs of our patients and communities have been ignored and trivialized by our medical and political leaders for so long -for decades- to get us to this point.  It is nice that we are slowly awakening to the fact that these socioeconomic issues are not going to go away on their own.  We need sufficient dollars federally invested and locally distributed, directed towards public programs where no citizen is excluded.   

Because of the vast level of trauma we see in our communities today, it is easy to understand why a patient may not feel safe to disclose their intimate personal information to some health professionals who perform the screening who behave towards patients in a judgmental and biased way.¹ 

My concern for this measure is how screening will be done (in a culturally, socially and psychologically safe manner? in a trauma-informed manner?) and who would be doing the screening - were they trained to be trauma-informed, culturally- sensitive?  are they members of the community, Community Health Workers?

I would hope this measure includes efforts to collect feedback, in their words, how the patients feel about the health professional's performance of the screening.

REFERENCE:

1)  Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse. (2009)  https://publications.gc.ca/collections/collection_2010/aspc-phac/HP20-11-2009-eng.pdf

Our US towns and communities are struggling to keep up with the public's needs just as our health institutions are currently unable to meet the public's health care needs.  In a country as wealthy as ours it is shameful that so many of our families are left struggling to survive - let alone trying to thrive.  

It is unfortunate that the needs of our patients and communities have been ignored and trivialized by our medical and political leaders for so long -for decades- as they enacted policies that brought us to this point. It is my position that we need to conduct nationwide needs assessments for all of our communities and for all of our patients; until we gain a better understanding of the actual levels of community and patient needs, we will not be able to accurately estimate a sufficient amount of funding needed in order to serve the actual level of needs of our public.  It is nice that we are awakening to the fact that these socioeconomic issues are not going to go away on their own. We need sufficient dollars federally invested and locally distributed, directed towards public programs to ensure no American is excluded.    

Because of the vast level of trauma we see in our communities today, it is easy to understand why a patient may not psychologically and emotionally feel safe enough to disclose their intimate personal information to health professionals who perform the HRSNs screenings.¹ 

My concern for this measure is how screening will be done (in a culturally, socially and psychologically safe manner? in a trauma-informed manner?)  And who would be doing the screening - were they trained to be trauma-informed, culturally- sensitive?  are they members of the patient's own community, eg. Community Health Workers?

I would hope this measure includes efforts to collect feedback, in their words, how the patients feel about the health professional's performance of the screening -for continuous improvement of quality care and patient safety.

REFERENCE:

1)  Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse. (2009)  https://publications.gc.ca/collections/collection_2010/aspc-phac/HP20-11-2009-eng.pdf

Older adults hospitalized are at risk for adverse events: 1) "hospital disability" due to immobility during a hospital stay.  It is not uncommon for older hospitalized adults to require PT/OT or be discharged to a rehabilitation center; 2) experience delirium due to the change in the environment, daily routine, or inappropriate medication prescribing; and  3) miss identifying what matters at admission and during hospitalization.  The Age-Friendly Health Systems 4M model can provide hospital systems with a framework to deliver care centered around What Matters and sensitivity to avoiding inappropriate Medications, maintaining their current Mobility, and evaluating Mentation throughout the hospital visit. The AFHS offers action communities throughout the year to help hospital systems organize and direct care to the unique needs of older adults. 

My name is Kathryn Biasotti.  I am a nurse who has worked in the area of 

Quality, Risk, and Patient Safety for over three decades.  I am submitting this Public Comment because last year I found myself on the other side of healthcare advocating for my mother and brother. My brother died due to medical error and my mother ultimately survived but is deathly afraid ever to go back to the hospital. I recently joined Patient for Patine Safety US after following their opinion pieces for several years.  

I applaud CMS for developing a Measures Under Consideration list prioritizing patient safety and health equity.  Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience hospital harm, much of it preventable. An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses or the failure to communicate an accurate diagnosis.

This year we’ll reach the 25th Anniversary of To Err is Human, the National Academy of Sciences call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

We also are grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. We are pleased to know our experience matters and that our input was heard.

Resources:

o   To Err is Human

o   One in four patients harmed:

§  Bates et al, New England Journal of Medicine

§  Office of the Inspector General

o   Diagnostic safety in the United States: 795,000 deaths or injuries annually, British Medical Journal

Specific PRMR Recommendations: We encourage patient safety and health equity advocates to especially pay attention to the following measures and address them in your Public Comment:

MUC2023-188: Patient Safety Structural Measure

  Background:  This is a measure that asks hospital leaders to attest to whether their organization has established best practices in patient safety across 5 domains: 1) Leadership Commitment, 2) Strategy & Policy, 3) Culture of Safety & Learning, 4) Accountability & Transparency, and 5) Patient & Family Engagement. PFPS US strongly supports this recommendation. In the PRMR process, adoption was recommended with these conditions: “Publication of an implementation guide that documents how safety is to be measured and using data to narrow the scope before approving the measure for programs.”

 I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay, because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices.

Concerning the conditions articulated, we note: 1) The best way to generate additional data across the 5 PSSM domains is to implement the PSSM as soon as possible so that attestation data about what hospitals are doing can be gathered, analyzed, and used in improvement work. 2) There currently exists several best practice implementation guides readily available to hospitals, including Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template, the Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool, the CANDOR (Communication and Optimal Resolution) Toolkit, and the World Health Organization’s Global Patient Safety Action Plan, among others.  While we welcome additional tools, there is no reason to wait on their development.

Resources:

o   Patient Safety Structural Measure: Full text

o   Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template

o   Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool

o   CANDOR (Communication and Optimal Resolution) Toolkit

o   World Health Organization’s Global Patient Safety Action Plan

o   Ascension Health Public Comment

MUC2023-196: Age-Friendly Hospital Measure

  Background: The Age-Friendly Hospital Measure includes 5 domains that target high-yield points of intervention for older adults – 1) Eliciting Patient Healthcare Goals, 2) Responsible Medication Management, 3) Frailty Screening and Intervention (i.e., Mobility, Mentation, and Malnutrition, 4) Social Vulnerability (social isolation, economic insecurity, ageism, limited access to health care, caregiver stress, elder abuse), and 5) Age-Friendly Care Leadership. The measure encourages hospitals to reconceptualize the way they approach care for older patients with multiple medical, psychological, and social needs at the highest risk for adverse events and attest to whether they are implementing evidence-based best practices. It also emphasizes the importance of defining patient and caregiver goals not only for the immediate treatment decision but also for long-term health and aligning care with what the patient values. It was developed by a consortium of medical societies, led by the American College of Surgeons, that have identified older patients as a particularly vulnerable population. During the PRMR process, the measure received substantial support for intent and content, but questions were raised as the value of attestation measures vs. outcome or process measures.  No consensus was reached and so the measure was not recommended.  PFPS US disagrees with this recommendation and strongly supports inclusion in the Proposed Rule.

Resources:

o   Hartford Foundation Public Comment on the Age-Friendly Hospital Measure

  I am disappointed by the failure of the PRMR process to recommend the Age-Friendly Hospital Measure, especially given how much support there was articulated for its intent and evidence-based content. We agree with the comments expressed by the Hartford Foundation and the consortium of professional associations, led by the American College of Surgeons, who are the developers of this measure, that it has the potential to improve patient safety and outcomes for an increasingly vulnerable population of older Americans. Measures like this, which have a structural “attestation” component, are a useful complement to other outcome and process measures. They send a signal to organizational leadership and governance about what patients, policymakers, and medical professionals expect to see prioritized. Public reporting of the measure has the potential to be actionable information for older patients and their caregivers.

MUC2023-199: Connection to Community Service Provider

MUC2023-210: Resolution of At Least 1 Health-Related Social Need

These two measures were discussed together during the PRMR process.  MUC2023-199 tracks referrals of patients with health-related social needs (HRSNs) -- including food insecurity, housing instability, transportation problems, utility help needs, or interpersonal safety – who are referred to a Community Service Provider. MUC2023-210 tracks whether at least one of the HRSNs referred to a community service provider was resolved. There was support for the intent of the measure during the PRMR discussion, but a lot of concern was expressed that hospitals that make referrals to community organizations would be judged badly if the HRSN was not resolved by the community-based service provider. PFPS US disagrees with the recommendation and strongly supports the implementation of these two measures.

 I am disappointed by the failure to recommend the Connection to Community Service Provider measure and the Resolution of At Least 1 Health-Related Social Need measure. I know that many hospitals are responsible for connecting patients in need to community resources and believe that organizations who are doing this should be acknowledged and given credit. I question whether hospitals will be viewed badly when a health-related social need is not resolved by a community-based service provider after a referral from the hospital. On the contrary, I see the value in shining a light on gaps in community resources when a hospital's demonstrated willingness to make referrals cannot be accomplished because needed safety net services are not available.

MUC2023-138: ESRD Dialysis Patient Life Goals Survey (PaLS)

The PaLS is a patient self-report survey that includes eight items related to dialysis facility care team discussions about patient life goals, including whether the organization tracks who talks to patients about their life goals. The goal of the measure is to provide contextual information for both the patient and the facility to guide care team discussions. During the PRMR process, concern was expressed about patient survey fatigue.  Also, at the current time, the patient-reported survey tool is only available in English

I believe it is important for dialysis treatment providers to prompt discussion with ESRD patients about life goals to ensure treatment aligns with individual preferences. While I share the concern that the tools needed to implement this measure are only available in English, I support the implementation of this measure and further work in expanding its availability in other languages.

Thank you for increasing your commitment to the patient safety structural measures.  

Kathryn Biasotti, BSN, CPHRM, LNCC, MBA in Healthcare Management

My name is Carole Hemmelgarn and my support for the MUC2023-188: Patient Safety Structural Measure has not waivered. My nine-year-old daughter is an example of the 1 out of 4 patients who experience harm in hospitals that is preventable. A missed diagnosis, hospital acquired infection, and sepsis were all contributors to her death.

I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices.

 

This year is the 25th Anniversary of To Err is Human, the National Academy of Sciences call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

I applaud CMS for developing a Measures Under Consideration list that prioritizes patient safety and health equity. Change must start somewhere, and this represents change. While the Patient Safety Structural measure is not perfect it is elevating the importance of patient safety and moving it in the right direction.

I was grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. I am pleased to know patient and family experience matters and that our input was heard.

This is a measure that asks hospital leaders to attest to whether their organization has established best practices in patient safety across 5 domains: 1) Leadership Commitment, 2) Strategy & Policy, 3) Culture of Safety & Learning, 4) Accountability & Transparency, and 5) Patient & Family Engagement. PFPS US strongly supports this recommendation. In the PRMR process, adoption was recommended with these conditions: “Publication of an implementation guide that documents how safety is to be measured and using data to narrow the scope before approving the measure for programs.”

Concerning the conditions articulated, it is noted: 1) The best way to generate additional data across the 5 PSSM domains is to implement the PSSM as soon as possible so that attestation data about what hospitals are doing can be gathered, analyzed, and used in improvement work. 2) There currently exists several best practice implementation guides readily available to hospitals, including Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template, the Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool, the CANDOR (Communication and Optimal Resolution) Toolkit, and the World Health Organization’s Global Patient Safety Action Plan, among others.  While we welcome additional tools, there is no reason to wait on their development.


 

• Resources:
  o   Patient Safety Structural Measure: Full text
  o   Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template
  o   Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool
  o   CANDOR (Communication and Optimal Resolution) Toolkit
  o   World Health Organization’s Global Patient Safety Action Plan
  o   Ascension Health Public Comment
  o   To Err is Human
  o   One in four patients harmed:

§  Bates et al, New England Journal of Medicine
§  Office of the Inspector General
o  Diagnostic safety in the United States: 795,000 deaths or injuries annually, British Medical Journal

I support this measure because patient safety should be a priority for every organization.

Respectfully,

Carole Hemmelgarn

Dear Centers for Medicare & Medicaid Services,

We commend CMS for developing a Measures Under Consideration list prioritizing patient safety and health equity. Harm, bias, and discrimination are problems embedded in our healthcare system affecting everyone—patients, families, clinicians—anyone who needs or provides care. There are constant studies bringing the consequence of the embedded problems into harsh light. We believe structured measures will improve these problems.

2024 is the 25^th Anniversary of To Err is Human, the National Academy of Sciences call to improve patient safety. We remain far from reaching the patient safety goals defined in the report. These challenges and the slow progress toward greater safety and equity, make CMS leadership extremely important and powerful. As Americans, we expect our health systems to be safe for all of us, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

We appreciate the opportunity to share our own experiences and those of our loved ones, as we are often driven to advocacy because the health care system has harmed us. We are pleased to know our experiences and input valued.

We strongly support MUC2023-188: Patient Safety Structural Measure without delay as it asks hospital leaders to publicly attest to their organization’s establishment of best practices in following domains: 

1) Leadership Commitment

2) Strategy & Policy

3) Culture of Safety & Learning

4) Accountability & Transparency

5) Patient & Family Engagement. 

These measures have the potential to improve patient safety and reduce health inequities. Public reporting by hospital leaders will help Americans identify hospitals that have implemented patient safety and health equity best practices and those that have not. Implementing these measures without delay will allow data to be analyzed and used for improvements. 

There are several best practice guides readily available to hospitals to aid in complying with the structural measures. New tools will always be welcomed, but there is no reason to wait on their development. 

Sincerely,

Transparency and Reporting Committee, Patients for Patient Safety, US

Leilani Schweitzer

Carole Hemmelgarn

Rebeka Acosta

Ariana Longley

Heon-Jae Jeong

Dave Mayer

Donna Prosser

Sally Kerr

Jeff Brown

Suz Schrant

The Healthcare Nutrition Council[1] ‎(HNC) supports CMS’ recognition of the impact of malnutrition health outcomes for ‎adult patients of all ages. Thus, as we have previously commented we support expanding the ages (from 65 years and older to 18 ‎years and older) for the Measure Under Consideration (MUC) MUC2023-114 “Global Malnutrition ‎Composite Score” (GMSC) and the expanded measure’s inclusion in the Hospital Inpatient Quality Reporting Program (Hospital ‎IQR Program) and the Promoting Interoperability Program (PI) set. HNC is an association representing ‎manufacturers ‎ of enteral nutrition (EN) formulas and oral nutrition supplements (ONS), parenteral ‎nutrition (PN) formulas, supplies and equipment. Our mission is to improve health by advancing policies ‎that address and raise awareness of nutrition and its impact on patient outcomes and healthcare costs. ‎Our organization aims to promote nutritional screening, diagnosis, assessment, appropriate and timely ‎clinical nutrition interventions, as well as to promote patient access to specialized nutrition support products/services for patients of ‎all ages and across the continuum of care.‎

We are encouraged by the Pre-Rulemaking Review (PRMRP) committee’s recent vote to recommend with conditions the expanded GMCS. Evidence documents malnourished patients experienced up to 5x risk of in-hospital mortality, up to 2x higher hospital costs, up to 2x longer length ‎‎of stay, and 55% higher readmissions than discharges without malnutrition.‎ 30-day readmissions among non-maternal and ‎non-neonatal inpatient stays related to malnutrition are 25.8% for 18–39-years of age and 26.3% for 40–64 years of age.‎^[2]  The average costs per readmission for patients with malnutrition were found to be 26-34% higher ($16,900 to $17,900) compared to those without malnutrition ($13,400).^[3] Therefore, expanding the GMCS to all adults age 18 and over will benefit both patients and healthcare systems. 

One of the conditions for consideration included in the PRMRP committee report was the addition of hospital-acquired malnutrition and high-risk nutritional practices in screening and assessment. Nutritional deterioration in hospitals is common among previously well-nourished as well as nutritionally compromised patients, with studies reporting that 10%-65% of patients experienced nutritional decline.^[4] It is for this reason that adult nutritional care pathways[5] recommend rescreening patients during their hospital stay to detect malnutrition, and many hospital inpatient screening policies include rescreening if the initial screen is negative for malnutrition risk to capture patients who may experience a decline in nutrition status or developed malnutrition during their stay. 

The current timing of the measure observations in the expanded GMCS does not preclude nutritional ‎screening and assessments that occur later in the hospitalization from counting toward measure ‎performance.‎ Yet, given that the average length of stay at US hospitals is 4.5 days,[6] it is appropriate that the GMCS measure currently prioritizes the absence of malnutrition or risk of malnutrition on admission. The ability to update the GMCS in the future allows for addressing how to ensure that nutritional status is captured accurately throughout an in-patient stay. 

Malnutrition care remains a critical gap area that is associated with multiple poor health outcomes, including hospital readmissions, extended lengths of stay, and quality of life. Malnutrition is also widely recognized as having a significant role in health outcomes and healthcare costs. It is important that CMS and others include robust nutrition measures in its quality reporting programs for adult healthcare, including and especially the IQR Program. HNC therefore offers its strong support for the addition of the Global Malnutrition Composite Score in the Hospital IQR program and PI set expanded to include all adults aged 18 years and over. HNC also encourages all stakeholders to continue advancing other nutritional-related measures for inclusion in CMS and other quality programs, and we stand ready to work with all stakeholders on this important initiative. 

HNC thanks CMS for allowing us the opportunity to provide feedback on the inclusion of the expanded GMCS measures. Should you wish to discuss these comments further, please contact Sydni Arnone at [email protected]. 

Sincerely,

Robert Rankin

Executive Director
 

[1] HNC members are Abbott Nutrition, Nestle Healthcare Nutrition, and Nutricia North America. 

[2] Barrett ML, Bailey MK, Owens PL. Non-maternal and Non-neonatal Inpatient Stays in the United States Involving ‎Malnutrition, 2016. Last Accessed December 6, 2023. U.S. Agency for Healthcare Research and Quality. Available: ‎https://www.hcup-us.ahrq.gov/reports/HCUPMalnutritionHospReport_083018.pdf.

[3] Fingar K, Weiss A, Barrett M, Elixhauser A, Steiner C, Guenter P, and Hise Brown M. All-Cause Readmissions Following Hospital Stays for Patients with Malnutrition, 2013. HCUP Statistical Brief #218. 2018. 1-18

[4] Cass AR, Charlton KE. Prevalence of hospital-acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: A systematic review of the evidence. J Hum Nutr Diet. 2022 Dec;35(6):1043-1058. doi: 10.1111/jhn.13009. Epub 2022 Apr 26. PMID: 35377487; PMCID: PMC9790482.

[5] “ASPEN Adult Nutrition Care Pathway” American Society for Parenteral and Enteral Nutrition. Updated September 14, 2022. https://www.nutritioncare.org/uploadedFiles/Documents/Malnutrition/Adult-Nutrition-Pathway_9.14.22.pdf

[6] “Hospital average length of stay by state” Definitive Healthcare. June 21, 2023. https://www.definitivehc.com/resources/healthcare-insights/average-length-of-stay-by-state#:~:text=What%20is%20the%20average%20length,hospital%20patients%20is%204.5%20days

The Healthcare Nutrition Council[1] ‎(HNC) supports CMS’ recognition of the impact of malnutrition health outcomes for ‎adult patients of all ages. Thus, as we have previously commented we support expanding the ages (from 65 years and older to 18 ‎years and older) for the Measure Under Consideration (MUC) MUC2023-114 “Global Malnutrition ‎Composite Score” (GMSC) and the expanded measure’s inclusion in the Hospital Inpatient Quality Reporting Program (Hospital ‎IQR Program) and the Promoting Interoperability Program (PI) set. HNC is an association representing ‎manufacturers ‎ of enteral nutrition (EN) formulas and oral nutrition supplements (ONS), parenteral ‎nutrition (PN) formulas, supplies and equipment. Our mission is to improve health by advancing policies ‎that address and raise awareness of nutrition and its impact on patient outcomes and healthcare costs. ‎Our organization aims to promote nutritional screening, diagnosis, assessment, appropriate and timely ‎clinical nutrition interventions, as well as to promote patient access to specialized nutrition support products/services for patients of ‎all ages and across the continuum of care.‎

We are encouraged by the Pre-Rulemaking Review (PRMRP) committee’s recent vote to recommend with conditions the expanded GMCS. Evidence documents malnourished patients experienced up to 5x risk of in-hospital mortality, up to 2x higher hospital costs, up to 2x longer length ‎‎of stay, and 55% higher readmissions than discharges without malnutrition.‎ 30-day readmissions among non-maternal and ‎non-neonatal inpatient stays related to malnutrition are 25.8% for 18–39-years of age and 26.3% for 40–64 years of age.‎^[2]  The average costs per readmission for patients with malnutrition were found to be 26-34% higher ($16,900 to $17,900) compared to those without malnutrition ($13,400).^[3] Therefore, expanding the GMCS to all adults age 18 and over will benefit both patients and healthcare systems. 

One of the conditions for consideration included in the PRMRP committee report was the addition of hospital-acquired malnutrition and high-risk nutritional practices in screening and assessment. Nutritional deterioration in hospitals is common among previously well-nourished as well as nutritionally compromised patients, with studies reporting that 10%-65% of patients experienced nutritional decline.^[4] It is for this reason that adult nutritional care pathways[5] recommend rescreening patients during their hospital stay to detect malnutrition, and many hospital inpatient screening policies include rescreening if the initial screen is negative for malnutrition risk to capture patients who may experience a decline in nutrition status or developed malnutrition during their stay. 

The current timing of the measure observations in the expanded GMCS does not preclude nutritional ‎screening and assessments that occur later in the hospitalization from counting toward measure ‎performance.‎ Yet, given that the average length of stay at US hospitals is 4.5 days,[6] it is appropriate that the GMCS measure currently prioritizes the absence of malnutrition or risk of malnutrition on admission. The ability to update the GMCS in the future allows for addressing how to ensure that nutritional status is captured accurately throughout an in-patient stay. 

Malnutrition care remains a critical gap area that is associated with multiple poor health outcomes, including hospital readmissions, extended lengths of stay, and quality of life. Malnutrition is also widely recognized as having a significant role in health outcomes and healthcare costs. It is important that CMS and others include robust nutrition measures in its quality reporting programs for adult healthcare, including and especially the IQR Program. HNC therefore offers its strong support for the addition of the Global Malnutrition Composite Score in the Hospital IQR program and PI set expanded to include all adults aged 18 years and over. HNC also encourages all stakeholders to continue advancing other nutritional-related measures for inclusion in CMS and other quality programs, and we stand ready to work with all stakeholders on this important initiative. 

HNC thanks CMS for allowing us the opportunity to provide feedback on the inclusion of the expanded GMCS measures. Should you wish to discuss these comments further, please contact Sydni Arnone at [email protected]. 

Sincerely,

Robert Rankin

Executive Director

[1] HNC members are Abbott Nutrition, Nestle Healthcare Nutrition, and Nutricia North America. 

[2] Barrett ML, Bailey MK, Owens PL. Non-maternal and Non-neonatal Inpatient Stays in the United States Involving ‎Malnutrition, 2016. Last Accessed December 6, 2023. U.S. Agency for Healthcare Research and Quality. Available: ‎https://www.hcup-us.ahrq.gov/reports/HCUPMalnutritionHospReport_083018.pdf.

[3] Fingar K, Weiss A, Barrett M, Elixhauser A, Steiner C, Guenter P, and Hise Brown M. All-Cause Readmissions Following Hospital Stays for Patients with Malnutrition, 2013. HCUP Statistical Brief #218. 2018. 1-18

[4] Cass AR, Charlton KE. Prevalence of hospital-acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: A systematic review of the evidence. J Hum Nutr Diet. 2022 Dec;35(6):1043-1058. doi: 10.1111/jhn.13009. Epub 2022 Apr 26. PMID: 35377487; PMCID: PMC9790482.

[5] “ASPEN Adult Nutrition Care Pathway” American Society for Parenteral and Enteral Nutrition. Updated September 14, 2022. https://www.nutritioncare.org/uploadedFiles/Documents/Malnutrition/Adult-Nutrition-Pathway_9.14.22.pdf

[6] “Hospital average length of stay by state” Definitive Healthcare. June 21, 2023. https://www.definitivehc.com/resources/healthcare-insights/average-length-of-stay-by-state#:~:text=What%20is%20the%20average%20length,hospital%20patients%20is%204.5%20days