PRMR MUC List Commenting

Hello, My name is Jane Tilly, DrPH and I have 40 years of work experience in the public health field, including 10 years with the Department of Health and Human Services.  I am writing to strongly support Patient Safety Structural Measure Number: MUC2023-188. 

My support comes from knowledge I have gained through my research, training, and the personal experiences of loved ones. Many people I know have been harmed due to hospital errors. The worst example comes from my mother's death experience. She suffered hospital staff's attempts to resuscitate her as she was dying. This happened although my mother had signed a do not resuscitate order two days before her death, in consultation with her attending physician at the hospital. Perhaps there is a more painful way to die, but I can't think of one. My mother's suffering and pain was absolutely unnecessary.  A second example is that an older friend of mine was hit by a car, went to the hospital emergency room, and had a series of tests, including X-rays. She was sent home and told she had bruising on her left leg. The next morning, after having hobbled around on that leg, the hospital called her and told her to come back to the emergency department immediately. A radiologist took another look at her X-rays and found out that she had a broken tibia. Again, unnecessary suffering due to hospital error. Both of these errors were entirely avoidable and caused pain and distress to my mother and friend. Hospitals are capable of much better and safer care.  

Implementation of MUC2023-188 will reduce hospital error and the accompanying patient suffering. The Measure provides critical guidance to hospital leaders for improving the care their hospitals provide by making care safer.  The Measure also will recognize the hospitals and health systems that are leaders in patient safety. The questions the Measure asks hospital leaders to attest to reflect what patients in the United States expect all hospitals to be doing. In addition, this Measure aligns with other national guidance such as the Safer Together: The National Action Plan to Advance Patient Safety, the CMS National Quality Strategy, and the September 2023 Report to the President: A Transformational Effort on Patient Safety, issued by the President’s Council of Advisors on Science and Technology.
 

Due to my experiences and those of family and friends, I strongly support the Patient Safety Structural Measure. Hospitals and their leadership can and should make patient care much safer. Thank you for this opportunity to make this public comment. Jane Tilly, DrPH

MUC2023-164, Adult COVID-19 Vaccination Status is being considered for inclusion in the MIPS Program. The AHA recognizes that the COVID-19 vaccination is a critical part of the nation’s strategy to counter the spread of COVID-19, and we strongly support efforts to promote it. 

In 2022, we had concerns with this measure as it was specified for inclusion in the MIPS program since it did not include denominator exceptions for medical reasons for patients not being up-to-date on their vaccinations. However, now that the measure contains this exception, the AHA supports its inclusion in the program. 

MUC2023-175: Facility Commitment to Health Equity is being proposed for inclusion in the ASCQR, Hospital OQR, and REHQR Programs.

The AHA is committed to health equity and improving social determinants of health and supports the implementation of measures intended to improve care to underserved populations. The significant decline in deaths from coronary heart disease and stroke is considered one of the top ten achievements in public health over the past 100 years; however, these improvements have not been equitable across patient populations.[i] Racial and ethnic minority groups are more likely to face HRSNs, and CVD mortality rates have not declined in African American populations to the same extent as in white populations. These disparities are not specific to cardiovascular disease, as they are prevalent across the spectrum of healthcare, and can be attributed to several factors, including social determinants of health, structural and systemic racism, genetics, burden of traditional CVD risk factors, and treatment bias.[ii] 

While the AHA supports the intent of these measures, we have several concerns with their current states. First, the measures have not been reviewed or endorsed by a consensus-based entity. Also, there is not a documented practice-gap in recent literature and recent publications do not attribute changes of quality of care to these measures. 

Because of these concerns, the AHA supports this measure with the caveats that it will be monitored for unintended consequences, will undergo further evaluation for how they are improving care, and will be submitted for review and endorsement by a consensus-based entity.  

[i] Churchwell, K., Elkind, M.S.V., Benjamin, R.M., Carson, A.P., Chang, E.K., Lawrence, W., et al. (2020) Call to action: structural racism as a fundamental driver of health disparities. A presidential advisory from the American Heart Association. Circulation, 142:e454-e468.

[ii] Warner, J.J., Benjamin, I.J., Churchwell, K., Firestone, G., Gardner, T.J., Johnson, J.C., Ng-Osorio, J., et al. (2020) Advancing healthcare reform: the American Heart Association’s 2020 statement of principles for adequate, accessible, and affordable health care. A presidential advisory form the American Heart Association. Circulation, 141:e601-e614.

MUC2023-176 Hospital Commitment to Health Equity is being proposed for inclusion in the ASCQR, Hospital OQR, and REHQR Programs.

The AHA is committed to health equity and improving social determinants of health and supports the implementation of measures intended to improve care to underserved populations. The significant decline in deaths from coronary heart disease and stroke is considered one of the top ten achievements in public health over the past 100 years; however, these improvements have not been equitable across patient populations.[i] Racial and ethnic minority groups are more likely to face HRSNs, and CVD mortality rates have not declined in African American populations to the same extent as in white populations. These disparities are not specific to cardiovascular disease, as they are prevalent across the spectrum of healthcare, and can be attributed to several factors, including social determinants of health, structural and systemic racism, genetics, burden of traditional CVD risk factors, and treatment bias.[ii] 

While the AHA supports the intent of this measure, we have several concerns with its current state. First, the measure has not been reviewed or endorsed by a consensus-based entity. Also, there is not a documented practice-gap in recent literature and recent publications do not attribute changes of quality of care to this measure. 

Because of these concerns, the AHA supports this measure with the caveats that it will be monitored for unintended consequences, will undergo further evaluation for how it is improving care, and will be submitted for review and endorsement by a consensus-based entity.  

[i] Churchwell, K., Elkind, M.S.V., Benjamin, R.M., Carson, A.P., Chang, E.K., Lawrence, W., et al. (2020) Call to action: structural racism as a fundamental driver of health disparities. A presidential advisory from the American Heart Association. Circulation, 142:e454-e468.

[ii] Warner, J.J., Benjamin, I.J., Churchwell, K., Firestone, G., Gardner, T.J., Johnson, J.C., Ng-Osorio, J., et al. (2020) Advancing healthcare reform: the American Heart Association’s 2020 statement of principles for adequate, accessible, and affordable health care. A presidential advisory form the American Heart Association. Circulation, 141:e601-e614.

The AHA supports the addition of MUC2023-156: Screening of Social Drivers of Health to the ASCQR, the Hospital OQR Program, and the REHQRP. This measure determines whether patients’ social needs are being assessed and aligns with the AHA’s 2030 Impact Goal of Advancing Equity and Well-Being.[i]

The AHA believes that while the data collected in this measure will be valuable, it may be more appropriate if reported at the system or regional level. The AHA also has concerns about the data required for this measure, as required data elements may not be reliably documented using discrete data fields that can be captured electronically. This potential gap in electronic feasibility may place an additional burden on facilities as they attempt to capture required data.

As previously suggested in our comments submitted for MUC 2022, the AHA recommends adding economic insecurity as a social risk factor for screening. Economic insecurity is a social risk factor that can lead to many other social determinants of health. 

[i] Angell, S.Y., McConnell, M.V., Anderson, C.A.M., Bibbins-Domingo, K., Boyle, D.S., Capewell, S., Ezzati, M., et al (2020) The American Heart Association 2030 impact goal. A presidential advisory from the American Heart Association. Circulation, 141:e120-e138. DOI: 10.1161/CIR.0000000000000758

MUC2023-171: Screen Positive Rate for Social Drivers of health is being considered for the ASCQR, Hospital OQR Program, and the REHQRP. 

The AHA supports this measure for assessing unmet social needs and whether interventions are implemented for patients who screen positive. The AHA supports a stronger safety net with a broader focus on unmet needs, such as health counseling, nutrition and physical activity programs, affordable housing, and access to public transportation. A measure that supports the assessment of social needs and interventions when needed could help address these important social risk factors that lead to improvements in care. [i]

However, as during the 2022 MUC period, the AHA is concerned that clinicians who serve disadvantaged populations or practice in rural or low socioeconomic status communities may be unfairly penalized by this measure. While it is important to capture and address social drivers affecting patients’ health, providers treating disproportionate numbers of these patients ultimately require additional dedicated resources to implement such interventions. Because of these concerns, the AHA feels this measure may be more appropriate if reported at a system or regional level. 

[i] Churchwell, K., Elkind, M.S.V., Benjamin, R.M., Carson, A.P., Chang, E.K., Lawrence, W., et al. (2020) Call to action: structural racism as a fundamental driver of health disparities. A presidential advisory from the American Heart Association. Circulation, 142:e454-e468.

The AHA does not support MUC2023-199: Connection to Community Service Provider, being considered for inclusion in the Hospital IQR Program and the Medicare Shared Services Program.   

The AHA is committed to health equity and social determinants of care and supports these measures that will assist delivering high-quality of care to underserved populations. The significant decline in deaths from coronary heart disease and stroke is considered one of the top ten achievements in public health over the past 100 years; however, these improvements have not been equitable across patient populations. [i] Racial and ethnic minority groups are more likely to have HRSNs, and CVD mortality rates have not declined in African American populations to the same extent as in white populations. These health disparities are not specific to cardiovascular disease, as they are prevalent across the spectrum of healthcare, and can be attributed to several factors, including HRSNs. [ii]

While this measure was modified to allow clinicians/facilities 60 days from discharge to connect patients to a community service provider, rather than 60 days from screening, the AHA is still concerned that clinicians and facilities who serve disadvantaged populations or practice in rural or low socioeconomic status communities may be unfairly penalized. It is important to address social drivers affecting patients’ health, however, providers treating disproportionate numbers of these patients ultimately require additional dedicated resources to implement such interventions. Due to these circumstances, this measure may be more appropriate if reported at a system or regional level.

[i] Churchwell, K., Elkind, M.S.V., Benjamin, R.M., Carson, A.P., Chang, E.K., Lawrence, W., et al. (2020) Call to action: structural racism as a fundamental driver of health disparities. A presidential advisory from the American Heart Association. Circulation, 142:e454-e468.

[ii] Warner, J.J., Benjamin, I.J., Churchwell, K., Firestone, G., Gardner, T.J., Johnson, J.C., Ng-Osorio, J., et al. (2020) Advancing healthcare reform: the American Heart Association’s 2020 statement of principles for adequate, accessible, and affordable health care. A presidential advisory form the American Heart Association. Circulation, 141:e601-e614.

The AHA does not support MUC2023-210: Resolution of at Least 1 Health-Related Social Need, which is under consideration for inclusion in the Hospital IQR Program and the Medicare Shared Savings Program. 

This measure aligns with the AHA’s 2030 impact Goal of Advancing Equity and Well-Being. We support a stronger social safety net with a broader focus on unmet needs, such as counseling, nutrition and physical activity programs, affordable housing, and access to public transportation; and this measure can help improve these important social risk factors that can lead to improvement in patient care. [i]

While this measure was modified to allow for the resolution of the health-related social need to take place 12 months after discharge rather than screening, the AHA is still concerned that clinicians who serve disadvantaged populations or practice in rural or low socioeconomic status communities may be unfairly penalized. It is important to address social drivers affecting patients’ health, however, providers treating disproportionate numbers of these patients ultimately require additional dedicated resources to implement such interventions. Due to these circumstances, we feel this measure may be more appropriate if reported at a system or regional level.

[i] Angell, S.Y., McConnell, M.V., Anderson, C.A.M., Bibbins-Domingo, K., Boyle, D.S., Capewell, S., Ezzati, M., et al (2020) The American Heart Association 2030 impact goal. A presidential advisory from the American Heart Association. Circulation, 141:e120-e138. DOI: 10.1161/CIR.0000000000000758

The AHA understands the importance of identifying disparities in care, which is the intent of MUC2023-139: Hospital Equity Index (HDI), which is again being considered for inclusion in the Hospital Inpatient Quality Reporting Program. We agree that this measure could be a valuable addition to the program and will aid in identifying variations in disparities in populations. 

However, this measure relies primarily on existing condition-specific 30-day readmission measures, in which the AHA has concerns. A number of peer-reviewed publications have shown an inverse relationship between reductions in readmissions and 30-day or 1-year mortality for certain clinical diagnoses (e.g., Heart Failure and Pneumonia).[i],[ii],[iii],[iv],[v] We are aware that publications[vi],[vii] released since the implementation of the 30-day condition-specific readmission measures and the Hospital Readmission Reduction Program incentives concluded that mortality did not increase. However, given the significant discrepancy between the findings in these reports and the serious implications for patients, we are restating concerns we have expressed in previous comments, including MUC 2022 comments. 

The AHA is concerned that the Health Equity Index (HDI) composite measure uses these condition-specific readmission measures in which there are discrepant findings (HF, Pneumonia). We encourage the HDI measure not be used until additional, independent research has further clarified the relationship between decreasing admissions and mortality. 

[i] Dharmarajan K, Wang Y, Lin Z, et al. Association of changing hospital readmission rates with mortality rates after hospital discharge. JAMA 2017; 318:270–8.

[ii] Gupta A, Allen LA, Bhatt DL, et al. Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure. JAMA Cardiol. 2018;3:44–53.

[iii] Khera R, Pandey A, Ayers CR, et al. Contemporary epidemiology of heart failure in fee-for service Medicare beneficiaries across healthcare settings. Circ Heart Fail 2017;10:e004402.

[iv] Chatterjee P, Joynt Maddox KE. US National Trends in Mortality From Acute Myocardial Infarction and Heart Failure: Policy Success or Failure? JAMA Cardiol. 2018; 3(4):336-340.

[v] Rishi K,  Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the Hospital Readmissions Reduction Program with Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia JAMA. 2018 Dec 25;320(24):2542-2552.

[vi] Medicare Payment Advisory Commission. June 2018 Report to the Congress: Medicare and the health care delivery system: Chapter 1 mandated report: the effects of the hospital readmissions reduction program. http://www.medpac.gov/-documents-/reports . Accessed June 10, 2019

[vii] Khera R, Dharmarajan K, Wang Y, Lin Z, Bernheim SM, Wang Y, Normand ST, Krumholz HM. Association of the Hospital Readmissions Reduction Program With Mortality During and After Hospitalization for Acute Myocardial Infarction, Heart Failure, and Pneumonia. JAMA Network Open. 2018;1(5):e182777.

On behalf of the Alliance of Wound Care Stakeholders, I am pleased to provide the attached comments in support of MUC 2023-114, expansion of the Global Malnutrition Composite Score to include all adults 18 years of age and older.  We strongly recommend that CMS consider adopting MUC 2023-114 into the Hospital IQR program.

I am writing in support of the Patient Safety Structural Measure, number MUC2023-188,on the CMS list of Measures Under Consideration.  I recently retired from work in the field of patient safety.  

I support this measure because it states the kind of patient safety best practices I believe U.S. hospitals should follow.

As the person who advocated for both of my parents in health care settings during their final years, and as a person who has herself been a patient, I expect these best practices to be in place.  

I think it is important that hospital leaders and boards of directors prioritize patient safety and are actively engaged in assuring implementation of patient safety measures.  Their patient safety strategic goal should be "zero preventable harm," because that is the lens that will promote improvement in patient safety practices. 

Hospitals must establish a culture of safety that will engage all staff.  These systems must ensure that the organization LEARNS from medical errors or other challenges that put patients at risk.  These systems must also address all forms of bias and discrimination, whether institutional, structural, or personal, because such discrimination undermines the provision of good medical care.  

Hospitals must have systems in place for internal reporting of harm events and near misses, and must unfailingly be open and honest with patients and families when harm events occur.  Hospitals must also report these events to government agencies, accreditation bodies, and patient safety organizations in their jurisdiction.  Finally, hospitals must provide support for patients and families, as well as involved medical staff and other care providers.

Hospitals should also follow the recommendations in the Better Together report of the President's Council of Advisors on Science and Technology by engaging patients and family members inpatient safety work.   Medical records are an area that could benefit from the attention of both hospital staff and patients/families.  In addition to reducing obstacles to access to records, and eliminating the many barriers to transferring records from one provider to another,  we. must develop workable processes for correcting erroneous information that has found its way into a medical record.  

I appreciate the opportunity to comment. 

Sincerely,

Beth Kaye

5102 NE 30th Avenue

Portland,  OR. 97211

I am writing in personal support of the Patient Safety Structural Measure (#MUC2023-188) in the CMS Measures Under Consideration. 

Background:

My work in patient safety was initiated by the loss of my nine-year-old daughter, Alyssa, to preventable medical errors. The first error was unintentional, but it was the subsequent harms that were intentional. Those harms ranged from lack of transparency, honesty, and truth telling after the event to creating a just and learning culture. Silence was the prevailing sound reverberating from the organization. As a result of my experience, I have harnessed my grief, passion, and energy in fighting for accountability and transparency in healthcare, incorporating patients and families into the improvement efforts, and learning from the mistakes to avoid harming others in the future.

I serve as a Co-Founder of Patients for Patient Safety, which represents patients committed to making our healthcare systems safer, reducing preventable harm, and advancing transparency towards learning when harm occurs. I was on the Governing Board of the Collaborative for Accountability and Improvement, I am currently on the on Solutions for Patient Safety (SPS) Board of Directors, a pediatric safety learning network, Leapfrog Patient and Family Caregiver Expert Panel, and the Diagnostic Excellence Committee at NQF. Finally, I served on the PSSM technical expert panel (TEP).

The Patient Safety Structural Metric:

The Patient Safety Structural Metric (PSSM) provides much needed guidance as to the structural ways that health systems can deliver safer care and aligns in its domains with other national guidance such as the AHRQ National Action Plan. 

I support the PSSM for the following reasons:

1. It demands accountability and transparency after harm which is a moral and ethical right all patients and families deserve.
2. Prioritizes involving patients and families in co-production and improvement work.
3. Learning occurs through event reviews and improvement efforts and dissemination is encouraged through large-scale learning network(s).
4. Governing boards are educated on patient safety and held accountable. 

While I am supportive of all five domains, I would like to specifically address Domain 4: Accountability and Transparency. Since my daughter died, I have dedicated much of my time to improving accountability and transparency. I was part of developing AHRQ’s Communication and Optimal Resolution (CANDOR) toolkit, written articles discussing transparency, and have spoken nationally and internationally on this topic. Patients and families deserve transparent and honest conversations after harm events. Requiring organizations to implement and embed evidence-based communication and resolution programs benefits all parties. Having a designed structure from reporting of harms, learning from event reviews, communicating transparently with patients, families, and staff, providing financial and emotional support for patients and families, and caring for healthcare providers, and the organization after medical errors. Communicating after harm events should be the standard of care and not default to a deny and defend strategy.

The Patient Safety Structural Measure elevates patient safety as a priority in healthcare and encourages positive actions and accountability to make care safer for organizations, healthcare providers, and patients and families. It is a positive step in the right direction towards safer care. Thank you for considering my public comment in support of the Patient Safety Structural Measure. 

Respectfully,

Carole Hemmelgarn

Re: MUC2023-188

My name is Joanne Spetz. I am faculty at the University of California, San Francisco, but write as an individual. I am a health services researcher and have conducted numerous studies of the quality of hospital care and the roles of the professionals who work in hospitals in delivering care. I write in support of the Patient Safety Structural Measure (#MUC2023-188) on the CMS list of Measures Under Consideration.

This proposed measure states the kinds of patient safety best practices that all hospitals should have. The proposed measure would make it clear that hospital leaders and boards of directors must prioritize patient safety and be actively engaged in making sure the right safety practices are in place. The proposed measure begins with the goal that hospitals adopt as their goal “zero preventable harm”. Even if that goal is aspirational, it should be what every hospital is aiming to achieve. Historically, hospitals have been reimbursed the same as long as they meet a minimum quality standard, whereas they should be incentivized to aspire to the highest possible standard of no errors. 

Hospital leadership and managers establish a culture of safety that engages all its staff and puts in place systems for preventing and learning from medical errors or other problems that put patients at risk for harm or discrimination. But, hospitals that create sustainable and durable systems are not rewarded for the effort to create and sustain these systems. The proposal rule would help remedy this disconnection. A key component of achieving zero harm is that hospitals have systems in place for reporting harm events and being open and honest with patients and the public when harm events occur. As a researcher and health care consumer, I also expect hospitals to report their events to government agencies or other bodies that focus on learning and prevention.  Hospitals should engage the patients and families they serve in patient safety work.  They should also be focused on helping patients access our medical records and correct errors in them when we find them.

For all these reasons I strongly support the Patient Safety Structural Measure.  Thank you for this opportunity to make this public comment.

Sincerely,

Joanne Spetz

 

NJ Advocates for Aging Well asks CMS to adopt the Age Friendly Hospital Measure, which will have a major impact on older adults and their families.  In both my professional and personal experience,  this measure is necessary not only to deliver better an appropriate care, but to prepare hospitals for the changing demographics and needs of an increasingly gaging population.  

Currently, our health systems are fragmented which makes it difficult to navigate the increased health care needs as one ages.  Older adults are often not able, physically or cognitively, to navigate on their own, and families are struggling to keep up.  An age-friendly reframing will benefit not only the patients but the family, caregivers and health system with improved outcomes and patient-centered care.

Please see attached comments on behalf of the National Organization of Rheumatology Management (NORM). 

Please see attached comments from the Coalition of State Rheumatology Organizations (CSRO). 

Please find attached the Oncology Nursing Society's comments in support of appropriate germline testing for ovarian cancer patients. 

The Home Centered Care Institute is a national nonprofit focused on advancing home-based primary care to ensure that older adults with complex care needs have increased access to quality care.  As an organization focused on educating and training the providers who care for this laregly geriatric population, we know that many - even those who are able to benefit from in-home care - end up spending many days in hopsitals. It is important to us that CMS include the Age-Friendly Hospital measure in the CMS Hospital Inpatient Quality Reporting (IQR) Program as it is a measure that will consider geriatric patients' full spectrum of needs.

We know how rapidly the US population is aging, and how challenged our current health care system is to adequately and safely care of this population.  The Age-Friendly Hospital measure is an updated measure that combines two measures previously reviewed by the National Quality Forum’s Measures Application Partnership (MAP) in 2022: the Geriatrics Hospital Measure (MUC-2022-112) and the Geriatrics Surgical Measure (MUC-2022-032). The new streamlined measure builds upon The John A. Hartford Foundation’s and the IHI’s Age-Friendly Health Systems’ framework known as the 4Ms (What Matters, Medication, Mentation, Mobility) by adding new domains including various aspects of social vulnerability which impact not only the patient but their caregiver(s). The new measure encourages hospital systems to evaluate and reconsider their approach to caring for older patients with complex care needs whether those are medical, psychological and/or social in nature.  

HCCI shares its strong support for the Age-Friendly Hospital measure for inclusion in the CMS Hospital IQR program. HCCI sees this as one of the many ways CMS can have a positive impact on the health care system. By including this new measure, CMS communicates its support of a more holistic approach to care and encourages hospitals to more fully embrace that approach, particularly for older, frail patients with complex care needs who deserve integrated, comprehensive, safe, and quality hospital-based care.   

The Home Centered Care Institute is a national nonprofit focused on advancing home-based primary care to ensure that older adults with complex care needs have increased access to quality care.  As an organization focused on educating and training the providers who care for this laregly geriatric population, we know that many - even those who are able to benefit from in-home care - end up spending many days in hopsitals. It is important to us that CMS include the Age-Friendly Hospital measure in the CMS Hospital Inpatient Quality Reporting (IQR) Program as it is a measure that will consider geriatric patients' full spectrum of needs.

We know how rapidly the US population is aging, and how challenged our current health care system is to adequately and safely care of this population.  The Age-Friendly Hospital measure is an updated measure that combines two measures previously reviewed by the National Quality Forum’s Measures Application Partnership (MAP) in 2022: the Geriatrics Hospital Measure (MUC-2022-112) and the Geriatrics Surgical Measure (MUC-2022-032). The new streamlined measure builds upon The John A. Hartford Foundation’s and the IHI’s Age-Friendly Health Systems’ framework known as the 4Ms (What Matters, Medication, Mentation, Mobility) by adding new domains including various aspects of social vulnerability which impact not only the patient but their caregiver(s). The new measure encourages hospital systems to evaluate and reconsider their approach to caring for older patients with complex care needs whether those are medical, psychological and/or social in nature.  

HCCI shares its strong support for the Age-Friendly Hospital measure for inclusion in the CMS Hospital IQR program. HCCI sees this as one of the many ways CMS can have a positive impact on the health care system. By including this new measure, CMS communicates its support of a more holistic approach to care and encourages hospitals to more fully embrace that approach, particularly for older, frail patients with complex care needs who deserve integrated, comprehensive, safe, and quality hospital-based care.   

On behalf of the Institute for Healthcare Improvement (IHI) and the IHI Lucian Leape Institute, I am submitting our comments on the Patient Safety Structural Measure. 

Respectfully submitted,

Patricia McGaffigan, MS, RN, CPPS

Vice President, Institute for Healthcare Improvement

President, Certification Board for Professionals in Patient Safety

My name is Julie Sacks, and I am the President of the Home Centered Care Institute (HCCI).  HCCI is a national nonprofit focused on advancing home-based primary care to ensure that older adults with complex care needs have increased access to quality care.  As an organization focused on educating and training the providers who care for this laregly geriatric population, we know that many - even those who are able to benefit from in-home care - end up spending many days in hopsitals. It is important to us that CMS include the Age-Friendly Hospital measure in the CMS Hospital Inpatient Quality Reporting (IQR) Program as it is a measure that will consider geriatric patients' full spectrum of needs.

We know how rapidly the US population is aging, and how challenged our current health care system is to adequately and safely care of this population.  The Age-Friendly Hospital measure is an updated measure that combines two measures previously reviewed by the National Quality Forum’s Measures Application Partnership (MAP) in 2022: the Geriatrics Hospital Measure (MUC-2022-112) and the Geriatrics Surgical Measure (MUC-2022-032). The new streamlined measure builds upon The John A. Hartford Foundation’s and the IHI’s Age-Friendly Health Systems’ framework known as the 4Ms (What Matters, Medication, Mentation, Mobility) by adding new domains including various aspects of social vulnerability which impact not only the patient but their caregiver(s). The new measure encourages hospital systems to evaluate and reconsider their approach to caring for older patients with complex care needs whether those are medical, psychological and/or social in nature.  

HCCI shares its strong support for the Age-Friendly Hospital measure for inclusion in the CMS Hospital IQR program. HCCI sees this as one of the many ways CMS can have a positive impact on the health care system. By including this new measure, CMS communicates its support of a more holistic approach to care and encourages hospitals to more fully embrace that approach, particularly for older, frail patients with complex care needs who deserve integrated, comprehensive, safe, and quality hospital-based care.   

To ensure that older adults receive the care that they need, especially follow-on and continued care, hospitals need to do more than simply screen their patients and refer them to non-emergency medical transportation services which may not operate in their home community or travel to the hospital at the needed days and times. Hospitals should be participating in local and regional transportation coordination efforts and fully engaged with CCAM’s work to develop a coordinated transportation network. When needed and allowed, hospitals should be financially supporting local transportation services or operating their own services. Without greater hospital participation, local transportation networks will become overwhelmed as the population ages, especially in rural and low-density areas.

While I appreciate the effort put into potential new HCAHPS sub-measures, I have great concern over the Restfulness of Hospital Environment proposed questions.  I work in a hospital and while we want our patients to get rest, sometimes this cannot occur due to the need for machines to keep the patient alive, medications that have to be given sometimes every few hours, and let's not forget the lab draws.  If anyone has been in a hospital of late, one should know that a hospital in not exactly the place to get rest, nor should it be.  We are here to heal and get patients back to the lives they had before.  I frequently tell patient that while we try our best to keep things as quiet as possible, some of the noise you hear and the interruptions of your sleep, are to get you well.  Also, there is a National Patient Safety goal about alarm fatigue.  I am not even going to think of the ramifications that could occur as a resulted of these proposed questions.

I seriously ask you to visit a hospital and sit in a patient room and experience what actually occurs.  If you really want to know what patients care about other than getting well and back to their lives, it is food.  Why are there not any questions about dietary and the food quality?  I am into my second decade of healthcare and patients care about food almost as much as they care about getting well.  

I have never commented on anything before in this forum, but these questions make me scratch my head to the WHY.  There is already an HCAHPS question on quietness!

My name is Heidi Rolfs.  Patient safety is important to me because I am a Registered Nurse and Board Certified Patient Advocate.  I write in support of the Patient Safety Structural Measure (#MUC2023-188) on the CMS list of Measures Under Consideration.

The reasons I support this measure is because it states the kinds of patient safety best practices I expect as a patient of all hospitals in the United States.  It is important to me that:

 - Hospitals adopt as their goal “zero preventable harm” as the patient safety strategic goal. Even if that goal is aspirational, it should be what every hospital is aiming to achieve.
-  Hospitals establish a culture of safety that engages all its staff and puts in place systems for preventing and learning from medical errors or other problems that put patients at risk for harm or discrimination.
-  Hospitals have systems in place for reporting harm events and being open and honest with patients and the public when harm events occur. I also expect hospitals to report their events to government agencies or other bodies that focus on learning and prevention.

- Hospitals should engage the patients and families they serve in patient safety work, including in reporting patient safety experiences and outcomes related to patient safety and discrimination.  

For all these reasons I strongly support the Patient Safety Structural Measure.  

Thank you for this opportunity to make this public comment.

Heidi Rolfs, RN, BCPA, QPHQ

Please see the Healthcare Nutrition Council's comments below and attached.

To Whom It May Concern,

The Healthcare Nutrition Council (HNC) supports the substantial change of expanding the age from 65 years and older to 18 years and older for the Measure Under Consideration (MUC) MUC2023-114 “Global Malnutrition Composite Score” for inclusion in the Hospital Inpatient Quality Reporting Program (Hospital IQR Program) and the Promoting Interoperability Program (PI) set, beginning with the 2024 performance year. HNC is an association representing manufacturers^[1]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 patient access to specialized nutrition support products and at all ages services throughout the continuum of care.

HNC supports continued and expanded application of the Global Malnutrition Composite Score (MUC2023-114) measure in the Hospital IQR Program and IP set. As CMS is aware, malnutrition is widely recognized as having a significant role in health outcomes and healthcare costs. Addressing malnutrition is essential to improving quality of care and outcomes for all patients. To just name a few important considerations, malnutrition has been shown to lead to increased complications, longer hospitalizations and more readmissions for patients being treated in facility settings. In addition, malnutrition is a risk factor for other adverse clinical events, such as falls, and is also tied to higher rates of stroke, heart failure, cancer, and COPD. 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]

Nutritional status, and by consequence malnutrition, is often influenced by a variety of social determinants of health (SODH). According to WHO, SDOHs are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”^[3] In many cases, SDOHs will have a drastic impact on the availability and quality of foods, how those foods can be prepared and consumed, and what foods will be commonly consumed as staple parts of the diet. As a result, SDOHs shape a population’s nutritional status and may result in certain populations, such as the elderly, disabled, and the poorest segments of society, becoming malnourished.

It is important that CMS and others include robust nutrition measures in its quality reporting programs for adults, 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 to 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 these 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, B. Braun Medical Inc., 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] World Health Organization. Social Determinants of Health.2019. Retrieved from http://www.who.int/social_determinants/en/‎

My name is Alex Cravanas.  I am writing as a Patient Safety Champion with Patients for Patient Safety US, which is a patient led network of people who feel that making healthcare safer is an urgent priority.  I write in support of the Patient Safety Structural Measure (#MUC2023-188) on the CMS list of Measures Under Consideration.

It is a fundamental moral and ethical responsibility to deliver safe care. Patient safety is at a crossroads, having seen a decline in commitment and systematic improvement for many years, accelerated by the pandemic. I believe that our hospitals and health systems have struggled in their commitment to safe care because it is under resourced and not a priority.

The Patient Safety Structural Measure provides much needed guidance to hospital leaders on the ways that they can deliver safer care. It also creates a way to recognize the hospitals and health systems who are exemplars for their leadership and action on patient safety. The questions the Patient Safety Structural Measure asks hospital leaders to attest to reflect what patients in the United States expect all hospitals to be doing, and it aligns with other national guidance such as the Safer Together: The National Action Plan to Advance Patient Safety.

For all these reasons I strongly support the Patient Safety Structural Measure.  Thank you for this opportunity to make this public comment.

The Healthcare Nutrition Council (HNC) supports the malnutrition component of the Measure Under Consideration (MUC) MUC2023-196 ‎“Age Friendly Hospital Measure” for inclusion in the Hospital Inpatient Quality Reporting Program (Hospital IQR Program), beginning with the 2024 performance year. HNC is an association representing manufacturers^[1]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 patient access to specialized nutrition support products and at all ages services throughout the continuum of care.

As CMS is aware, malnutrition is widely recognized as having a significant role in health outcomes and healthcare costs. Addressing malnutrition is essential to improving quality of care and outcomes for all patients. To name a few important considerations, malnutrition has been shown to lead to increased complications, longer hospitalizations and more readmissions for patients being treated in facility settings. In addition, malnutrition is a risk factor for other adverse clinical events, such as falls, and is also tied to higher rates of stroke, heart failure, cancer, and COPD. 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.^‎‎[2]

The Age Friendly Hospital measure (MUC2023-196) ‎pairs well with the Global Malnutrition Composite Score (GMCS) measure, as the components measured by the GMCS directly align with the requirements for activities one and two under domain three of the Age Friendly Hospital measure.

HNC appreciates and supports inclusion of malnutrition screening and the required action plans for older adults due to the impact malnutrition has on downstream complications and health risks. Moreover, implementing components of the GMCS would meet the requirements for the malnutrition components of this measure. HNC would like to emphasize the critical component of communicating nutrition care plans in discharge instructions and post-acute transfers to ensure that the conditions identified in the hospital are appropriately managed and treated after discharge, as disease-related malnutrition is a common reason for patients to be readmitted to hospitals.^[3] Communicating nutrition care plans in discharge instructions would help reduce readmission rate for patients with malnutrition; in which the average costs per readmission were found to be 26-34 percent higher ($16,900 to $17,900) compared to those without malnutrition ($13,400).^[4]

It is important that CMS and others include robust nutrition measures in its quality reporting programs for adults. HNC therefore offers its strong support for the addition of the Age Friendly Hospital measure in the Hospital IQR program. 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 these 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, B. Braun Medical Inc., 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] Alvarez-Hernandez J, Planas Vila M, Leon-Sanz M, et al. Prevalence and costs of malnutrition in hospitalized patients; the PREDyCES® Study. Nutr Hosp. 2012; 27(4): 1049-1059.

^[4] 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.

On behalf of the Alliance of Wound Care Stakeholders, I am pleased to submit comments in support of MUC2023-114, expansion of the Global Malnutrition Composite Score from 65 years of age and older to 18 years of age and older and highly recommend that CMS consider adoption  of the MUC 2023-114 into the Hospital IQR program.

AOTA supports the Hospital Harm – Falls with Injury measure for the Hospital Inpatient Quality Reporting Program and Medicare Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals. This measure will raise awareness of fall rates, improving patient safety and lowering healthcare costs. Occupational therapy practitioners are often involved with hospital falls programs and work to reduce fall risk by providing skilled, evidenced-based interventions that address physical, cognitive, and psychosocial factors inhibiting safe performance in meaningful everyday activities.

AOTA encourages the measure developer to review the denominator exclusion language. As written, the denominator exclusion of patients who have a fall diagnosis upon admission may cause confusion and inappropriate use of fall diagnosis in attempt to exclude patients from this measure. It is not clear that the fall diagnosis at admission pertains to a fall that occurred outside of the time of the inpatient hospitalization. 

AOTA supports advancement of the Hospital Harm - Postoperative Respiratory Failure, under the Hospital Inpatient Quality Reporting Program and Medicare Promoting Interoperability Program for Eligible Hospitals or Critical Access Hospitals. Postoperative respiratory failure impacts quality of life, overall healthcare costs, decreases participation in meaningful activities, and increases the risk for morbidity and mortality.

We encourage the measure developer to consider including non-elective hospitalizations with appropriate risk stratifications and denominator exclusions to further improve postoperative respiratory failure monitoring.  

AOTA supports advancement of the Global Malnutrition Composite Score measure under the Hospital Inpatient Quality Reporting Program and Medicare Promoting Interoperability Program for Eligible Hospitals or Critical Access Hospitals. Identifying and assessing malnutrition provides valuable data to the care team, including occupational therapy practitioners, who assess, and address factors associated with malnutrition such as feeding, eating, swallowing and health management. In addition, the best practice of the physician/eligible clinician recommending a medical diagnosis increases the likelihood that malnutrition will be addressed after care transitions out of the hospital. 

AOTA supports inclusion of the ESRD Dialysis Patient Life Goals Survey (PaLS) measure to the ESRD Quality Incentive Program. This measure will help ensure shared decision making in treatments that have a significant impact on quality of life and engagement in meaningful activities. Occupational therapy practitioners serve Medicare beneficiaries undergoing dialysis treatment, assisting clients to participate in meaningful life occupations by helping them modify or adapt their daily activities, which helps improve participation, and overall quality of life.

AOTA supports advancing the Initial Opioid Prescribing for Long Duration (IOP-LD) measure in Medicare’s Part C and D star rating. Pain is a top reason for seeking healthcare. Managing the use of opioid prescriptions may protect many against long-term opioid use. 

AOTA believes this measure may also help to support non-pharmacological interventions for pain. This includes occupational therapy as part of a comprehensive integrative pain management program. 

AOTA supports including the Hospital Patient Experience measure in the Hospital Inpatient QRP, Hospital VBP program, and the PPS-Exempt Cancer Hospital QRP. Rest and sleep are foundational occupations that affect patient function and quality of life, which occupational therapy practitioners address. Inadequate rest and sleep can contribute to poor performance in rehabilitation, decreased pain tolerance, delirium, and other conditions. Improvement in sleep may also improve outcomes in other areas of care.        

AOTA supports the Screening for Social Drivers of Health measure for the Ambulatory Surgical Center QRP, Hospital Outpatient QRP, and the Rural Emergency Hospital QRP. It is imperative to identify social factors that negatively impact healthcare outcomes and address social needs to reduce health inequities. 

AOTA encourages the measure developer to expand the list of applicable procedural codes to include occupational therapy evaluation/re-evaluation codes (97165-97168) and consider the occupational profile to capture social drivers of health.  

AOTA supports the Resolution of At Least 1 Health-Related Social Need measure in the Medicare Shared Savings Program and the Hospital Inpatient Quality Reporting Program.  Social needs impact an individual’s quality of life, health, and daily functioning. Understanding social needs impacting a patient’s wellbeing is an important aspect of quality healthcare delivery. Occupational therapy practitioners assess social drivers of health as part of the comprehensive evaluation process, including use of the occupational profile, and address social drivers of health through their client-centered interventions.

AOTA encourages the measure developer to consider including the occupational therapy, occupational profile to the list of screening tools and expand the list of applicable procedural codes to include occupational therapy evaluation/re-evaluation codes (97165-97168).

AOTA supports Screen Positive Rate for Social Drivers of Health. Social needs impact an individual’s quality of life, health, and daily functioning. Understanding social needs impacting a patient’s wellbeing is an important aspect of quality healthcare delivery, including the delivery of occupational therapy services. Occupational therapy practitioners assess social drivers of health as part of the comprehensive evaluation process, including use of the occupational profile, and address social drivers of health through their client-centered interventions.

AOTA encourages the measure developer to expand the list of applicable procedural codes to include occupational therapy evaluation codes (97165-97168) and consider the occupational profile to capture social drivers of health.

AOTA supports the advancement of the Patient-Reported Pain Interference Following Chemotherapy among Adults with Breast Cancer measure in the Merit-based Incentive Payment System. Occupational therapy practitioners play a critical role with clients to identify and incorporate self-management strategies into their daily routines to reduce pain, increase participation in meaningful activities, and improve quality of life. Ensuring pain is addressed will improve patient quality of life and participation in daily activities.

AOTA supports the advancement of the Timely Reassessment of Pain Impact measure in the Hospice QRP. Occupational therapy practitioners provide skilled, client-centered care to clients throughout the lifespan, including end of life and hospice care. Ensuring reassessment of pain will allow clients to participate in their chosen occupations during the end-of-life process.

AOTA supports adding the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure (Information Transfer PRO-PM) measure to the Hospital Outpatient QRP. Providing personalized, clear discharge instruction is important to compliance and follow through with medical recommendations. Several factors can influence a patient’s understanding of discharge instructions including health literacy level and functional cognition. 

AOTA supports efforts to advance health equity and believes it is critical for CMS to take steps to move away from the institutional biases that have plagued the reimbursement structure and healthcare system. Identifying and tracking these issues is a key step to addressing systemic problems. We support this proposed measure. 

For a patient experiencing health inequity, economic stability influencing food or housing insecurity, transportation, and interpersonal safety can impact their health condition and ability to access quality health care, as well as influence engagement and outcomes. Occupational therapy practitioners assess social drivers of health and address needs as part of the occupational therapy process. 

AOTA recommends monitoring the time and effort necessary to implement these domains, to ensure payment and resources support the work requested.  Some facilities may not currently have the resources to adequately participate in this important measure.

AOTA supports the intent of the Hospital Commitment to Health Equity measure. AOTA supports efforts to advance health equity and believes it is critical for CMS to take steps to move away from the institutional biases that have plagued the reimbursement structure and healthcare system. Identifying and tracking these issues is a key step to addressing systemic problems. 

For a patient experiencing health inequity, economic stability influencing food or housing insecurity, transportation, and interpersonal safety can impact their health condition and ability to access quality health care, as well as influence engagement and outcomes. Occupational therapy practitioners assess social drivers of health and address needs as part of the occupational therapy process.

AOTA recommends monitoring the time and effort necessary to implement these domains, to ensure payment and resources support the work requested.  Some facilities may not currently have the resources to adequately participate in this important measure.

AOTA supports the intent of the Age Friendly Hospital Measure. The Age Friendly Hospital measure addresses important areas that impact healthcare outcomes for older adults receiving care in a hospital, including occupational therapy services. 

AOTA supports advancing the Level I Denials Upheld Rate Measure in the Part C and D Star ratings. Medicare advantage denials can negatively impact access to critical healthcare services. Occupational therapy practitioners often see the impact of Medicare advantage denials while providing skilled services throughout the care continuum. This important measure is one of many actions that CMS can take to ensure clients with Medicare advantage receive the skilled, medically necessary services they need to achieve their highest practicable level of function and engage in meaningful activities. 

AOTA supports the Initiation and Engagement of Substance Use Disorder Treatment (IET) measure. Occupational therapy practitioners often provide services to persons with substance use disorder by implementing addiction recovery methods based on a client’s ability to address social, emotional, psychological, physical, and cognitive aspects of mental illness while facilitating increased independence in daily life. Substance use disorder (SUD) can exacerbate or worsen mental health issues, negatively impacting a persons quality of life, and lead to premature death. In addition to addressing SUD this measure will help plans gather data to provide education and outreach to improve access to care.

Ms. Chiquita Brooks-LaSure 

Administrator, Centers for Medicare & Medicaid Services 

Department of Health and Human Services, P.O. Box 8010 

Baltimore, MD 21244 

RE: Finalize Inclusion of NQF #3592e Global Malnutrition Composite Score for the FY 2024 Hospital Inpatient Quality Reporting Program 

Dear Ms. Brooks-LaSure: 

The International Council on Active Aging (ICAA) is submitting comments in response to the recent release of the FY 2023 MUC List. We are an association that leads, connects, and defines the active-aging industry and we support organizations and professionals who develop wellness environments and services for adults over age 50.

Establishing quality measures to help evaluate malnutrition care is an effective tool because healthy nutrition is vital for healthy aging. Thus, we were pleased when last year the Centers for Medicare & Medicaid Services adopted the Global Malnutrition Composite Score (GMCS) as an optional measure for the US Hospital Inpatient Prospective Payment System. We believe the recent inclusion on the 2023 MUC List of a GMCS that has been expanded to include adults over the age of 18 represents a further opportunity to support healthy aging for all. Good nutrition across the lifespan is fundamental for healthy aging (Rodríguez-Mañas et al, 2023). Therefore, we urge CMS to take action and adopt the GMCS (expanded to age 18+) in its payment programs.

Adoption of the expanded GMCS is critical to help address the under-diagnosis of malnutrition. Over 30% of hospitalized adults are affected by malnutrition (AHRQ 2020), but it is diagnosed in less than 9% of hospital patients (Guenter et al 2021 ). When malnutrition is not diagnosed, it imposes a serious burden on our healthcare system. As CMS commented when the original GMCS was proposed in 2022, “Hospitals have an opportunity to identify malnutrition during the patient admission process and to address it efficiently and effectively with individualized interventions that could optimize outcomes including.”

Another reason to address the gap in hospital identification and intervention for malnutrition is that malnutrition is related to health equity. For example, non-Hispanic Black Americans with malnutrition have a readmission rate over 26% compared to a rate of less than 19% for non-Hispanic White Americans (Wahid et al 2022). Screening and intervening for malnutrition can also help address food insecurity, which disproportionately impacts communities of color (Ojeda et al 2023).

Integrating nutrition and health was one of the five pillars of the Biden-Harris Administration’s historic White House Conference on Food, Nutrition, and Health. Adopting the expanded GMCS into CMS payment programs supports this goal and promotes quality malnutrition care and a wellness environment.

Sincerely,

Colin Milner

CEO/Founder

International Council on Active Aging

On behalf of the American Academy of Ophthalmology representing over 20,000  ophthalmologists in the United States, we appreciate the opportunity to provide feedback on the potential revisions to the Cataract Removal with Intraocular Lens (IOL) Implantation cost measure (MUC2023-201). Our organization has been an active participant in the ongoing effort to develop episode-based cost measures that more accurately reflect the care specialists are providing to Medicare beneficiaries. Please see the attached letter detailing our recommendations. 

The nation's ophthalmologists are committed to finding a solution that does not threaten our patients’ access to vision-restoring surgery, and our organizations welcome the opportunity to work with CMS to develop sensible cost measures. We look forward to working with you on these issues during the upcoming rulemaking cycle.

My name is _Julian Bene____.  Patient safety is important to me because my mother died in her 60s from an apparent breakdown in monitoring of anti-rejection drug effects after a kidney transplant. The hospital's evasiveness about the adverse event was very upsetting to my father and close family. I write in support of the Patient Safety Structural Measure (#MUC2023-188) on the CMS list of Measures Under Consideration.

The reasons I support this measure are 1) as a retired management consultant with many years of organizational observation and experience, it is clear that in the best organizations, people are encouraged to admit errors in order both to mitigate harm promptly and to avoid repeating them in future.  2)a trusted friend who is an anesthesiologist with a policy mindset supports this approach and I respect her judgment. 

It is important to me that:

 

1.     Hospital leaders and boards of directors prioritize patient safety and are actively engaged in making sure the right safety practices are in place. 

2.     Hospitals adopt as their goal “zero preventable harm” as the patient safety strategic goal. Even if that goal is aspirational, it should be what every hospital is aiming to achieve.

3.     Hospitals establish a culture of safety that engages all its staff and puts in place systems for preventing and learning from medical errors or other problems that put patients at risk for harm or discrimination.

4.     Hospitals have systems in place for reporting harm events and being open and honest with patients and the public when harm events occur. I also expect hospitals to report their events to government agencies or other bodies that focus on learning and prevention.

5.     Hospitals should engage the patients and families they serve in patient safety work.  They should also be focused on helping patients access our medical records and correct errors in them when we find them.

For all these reasons I strongly support the Patient Safety Structural Measure.  Thank you for this opportunity to make this public comment.

My name is Renee Bernard.  I've worked in healthcare for 25 years, first as a care provider then as a medicolegal consultant to hospitals and insurance companies. I have witnessed firsthand the harm of medical errors that stem from system issues.  I write in support of the Patient Safety Structural Measure (#MUC2023-188) on the CMS list of Measures Under Consideration.

The reasons I support this measure is because it states the kinds of patient safety best practices I expect as a patient of all hospitals in the United States.  It is important to me that:
 

1. Hospital leaders and boards of directors prioritize patient safety and are actively engaged in making sure the right safety practices are in place. 
2. Hospitals adopt as their goal “zero preventable harm” as the patient safety strategic goal. Even if that goal is aspirational, it should be what every hospital is aiming to achieve.
3. Hospitals establish a culture of safety that engages all its staff and puts in place systems for preventing and learning from medical errors or other problems that put patients at risk for harm or discrimination.
4. Hospitals have systems in place for reporting harm events and being open and honest with patients and the public when harm events occur. I also expect hospitals to report their events to government agencies or other bodies that focus on learning and prevention.
5. Hospitals should engage the patients and families they serve in patient safety work.  They should also be focused on helping patients access our medical records and correct errors in them when we find them.

For all these reasons I strongly support the Patient Safety Structural Measure.  Thank you for this opportunity to make this public comment.

 

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

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with kidney disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with kidney disease. 

While the RPA appreciates the value of patient-reported measures, we are concerned that this measure would add to the survey fatigue already faced by patients with ESRD. Patients are already expected to complete the following surveys: Patient Activation Measure (PAM) twice a year; PHQ9; KDQOL; iCAHPS (also twice a year); dialysis facility specific surveys such as wellness surveys, as well as patient satisfaction every time they are discharged from a facility or have a procedure. Consequently, response rates to surveys are frequently lower than desired and can result in questionable statistical significance. RPA recommends that the measure developer explore having the survey questions added to one of the other surveys, rather than adding addition surveys for patients and providers to track and administer.

Testing and Validity

This measure is proposed as a facility-level process measure assessing the percent of eligible patients in a given dialysis facility that completed at least one scorable item of the survey. However, only patient-level testing data on the survey instrument itself was provided; there was no information provided on the facility-level process measure being proposed for use. All information provided with the submission materials is on the survey t-score, based on the data collected during testing of the instrument—but the 
t-score is “currently not part of the calculation for process measure being proposed.” The submission notes in the measure specifications that prior to implementation at the dialysis facility level, the response rate will need to be calculated at the dialysis facility level; it is it is unclear why this was not done prior to submission. Detailed information (performance scores, reliability, validity) for the performance metric being proposed, as specified, is an immutable component of the consensus development and endorsement processes. Therefore, an assessment of the PaLS is not feasible in the absence of this information.

Finally, this measure was not recommended for endorsement by the NQF Renal Standing Committee or the CSAC and it is unclear whether any changes to have been made to address concerns raised by those groups. 

As always, RPA welcomes the opportunity to work collaboratively to improve the quality of care provided to the nation’s kidney patients. Any questions or comments regarding this correspondence should be directed to Amy Beckrich, RPA’s Director of Projects and Operations, at 301-468-3515 or [email protected].