PRMR MUC List Commenting

The Patient Safety Action Network appreciates the opportunity to comment on this measure.

We strongly support these new questions to the HCAPS survey. Combined, they will provide a fuller patient assessment of the care received in a hospital with some more specific questions. The questions regarding care coordination (146) are essential for safe patient care and lack of it is often identified as an issue when patient harm occurs. Restfulness (147) or lack thereof is among most common general complaints of hospital patients. Responsiveness of Hospital Staff (148) and providing useful information about a patient’s symptoms (149) cover additional important issues. We are interested in seeing which questions are being removed from the survey to make room for these new questions. We understand this will be revealed in the regulatory process, but it would be helpful to weigh the importance of the new v. the old. 

We have some concerns regarding certain exclusions where caregivers could provide valuable input, for example patients who died while in the hospital and those discharged to hospice or a nursing home. This is especially relevant to the Responsiveness of hospital staff because it includes a question about getting assistance to go to the bathroom, something these patients probably need more than others. 

PLEASE NOTE THIS IS NOT FOR ESRD MEASURE, but comments for Measure #172 - patient understanding of key information related to recovery after a facility based outpatient procedure: 

This was not listed in the drop down for hospital committee (or any other committee) comments but we strongly support this Patient Reported measure relating to the fastest growing way that people have surgery and other procedures. It is of great importance because it seeks information about the care patients received in both hospital based out patient departments and ambulatory surgical centers. Providing comparisons of patients' experiences across these two provider types should help people decide where they might want to receive care. We would like to see more of these types of measures that allow comparisons of various health care provider locations/types.  

We support this measure. However, it is unacceptable for the measure to only be available in English. We recommend that it not move forward without translations into Spanish and other prominent languages spoken by these patients. 

Ascension appreciates the opportunity to submit comments regarding 2023 measures under consideration for inclusion in Centers for Medicare & Medicaid (CMS) programs. 

Ascension is one of the nation’s leading non-profit and Catholic health systems, with a Mission of delivering compassionate, personalized care to all with special attention to persons living in poverty and those most vulnerable. In FY2022, Ascension provided $2.3 billion in care of persons living in poverty and other community benefit programs. Ascension includes approximately 139,000 associates and 36,000 aligned providers and operates more than 2,600 sites of care – including 139 hospitals in 19 states.

Patient Safety Structural Measure

We write specifically regarding one Measure Under Consideration for the Hospital Inpatient Quality Reporting Program (IQR) Program and PPS-Exempt Cancer Hospital Quality Reporting (PCHQR): MUC2023-188, the Patient Safety Structural Measure. For this measure, the hospital outcome is defined by the five patient safety domains, each containing multiple statements. A hospital must positively attest to all statements within a domain to receive one point for that domain (for a total of 0 – 5 points for the outcome). The five domains defining the numerator are: Domain 1: Leadership Commitment to Eliminating Preventable Harm; Domain 2: Strategic Planning & Organizational Policy; Domain 3: Culture of Safety & Learning Health System; Domain 4: Accountability & Transparency; and Domain 5: Patient & Family Engagement.

Ascension is committed to patient safety and fully supports effective and appropriate efforts to advance it. We are deeply committed to providing quality care to the communities we are privileged to serve and ensuring safety is foundational to this commitment. We believe any safety measure adopted into program measure sets should be data-driven, actionable, and workable. Consequently, Ascension strongly supports the use of the Patient Safety Structural Measure, and we applaud CMS for its efforts to incorporate this innovative measure. The Patient Safety Structural Measure is realistic and is a step in the right direction; we encourage the agency to incorporate more innovative measures like this instead of utilizing outcomes-based measures that are lagging indicators. 

Moreover, Ascension commends CMS’s proposal to add the Patient Safety Structural Measure because of its alignment with the National Action Plan for Advancing Patient Safety (National Action Plan), of which Ascension has been an early adopter. The National Action Plan includes four broad categories composed of seventeen recommendations to advance patient safety, with a focus on eliminating inequities at the point of care. These four categories (Culture, Leadership, and Governance; Patient and Family Engagement; Workforce Safety; and Learning System) align with the five domains outlined in the Patient Safety Structural Measure. Furthermore, both ensure interdependence amongst the scoring areas, which is key to driving meaningful change and advancing the goal of creating the safest health care for patients and those who care for them.

Due to this mirroring, we believe it would be helpful to share our real-world experience with the National Action Plan. When Ascension first integrated it across our system, we scored each of Ascension’s markets multiple times, then averaged these scores nationally. The focus provided by the National Action Plan is supporting our dedication to continuous improvement, and we have already seen significant progress to date. We anticipate that when we reassess our markets for the second time in spring of 2024, the data will reinforce this anecdotal evidence. 

In addition, we would like to specifically reference the question regarding whether organizations participate in a Patient Safety Organization (PSO) that submits data to the National Patient Safety Database. As a leading PSO that submits data to the National Patient Safety database, we applaud CMS for distinguishing the submission of patient safety data to PSOs as an effort that should be recognized and rewarded, and we appreciate such a connection. 

We are grateful for the engagement with stakeholders and patient safety experts to ensure the promotion of higher quality of care across hospitals and look forward to future opportunities to comment on and support the development of this and similar measures. 

Please see attached for comments from the National Kidney Foundation. 

Please see attached for comments from the National Kidney Foundation. 

Please see attached for comments from the National Kidney Foundation.