One notable change is a three-month delay in the start date, from Oct. 1, 2027, to Jan. 1, 2028. Performance periods will run on a standard calendar-year basis.

Key provisions that remain unchanged include the following.

• The model continues to apply to hospitals paid under the Inpatient PPS and OPPS, excluding hospitals located in Maryland and hospitals participating in the Transforming Episode Accountability Model.
• Hospitals will be held accountable for Medicare spending and quality of care for patients from the inpatient admission or outpatient procedure through 90 days after discharge.
• The model includes inpatient hip, knee and ankle replacements and reattachments under MS-DRGs 469, 470, 521 and 522, as well as outpatient hip and knee procedures under HCPCS codes 27130 and 27447.

Hospitals should use the additional time before implementation to evaluate episode spending, strengthen post-acute care partnerships and identify opportunities to improve quality performance. The Missouri Hospital Association will continue to monitor CMS guidance and share additional resources as implementation approaches.

Originally established by the Missouri Association for Healthcare Quality, this prestigious award recognizes professionals whose dedication, leadership and innovation have driven meaningful improvements in health care quality and patient care within their organizations and beyond.

Following the MoAHQ’s transition into the Quality Leader Learning Network, the former MoAHQ board, with the support of MHA, remains committed to carrying on the award's legacy and honoring outstanding quality professionals serving Missouri's communities. Submit a nomination today!

Designed to generate savings while maintaining quality of care, the CJR-X model would include both inpatient and outpatient settings and hold hospitals financially accountable for a full 90 days after discharge. 

In response to an increased number of inquiries, the Missouri Hospital Association developed the CJR-X Model Summary to provide hospitals with an overview of who would be affected, how the model would work, the reasons for the proposed expansion and MHA’s recommendations to CMS. 

The preview period began June 23 and will end Thursday, July 23. During this time, hospitals should review their hospital-specific report, available through the Hospital Quality Reporting system. Any questions about calculations should be submitted through the QualityNet Question and Answer Tool before 1 a.m. July 23.

Hospitals cannot correct or add claims data, and should not include personally identifiable information or protected health information. Instead, hospital teams should use the report ID number when referencing HSR content.

Measures in the report include:

• Foreign object retained after surgery

• Air embolism

• Blood incompatibility

• Falls and trauma (includes fractures, dislocations, intracranial injuries, crushing injuries, burns and other injuries)

You can find more information about the Publicly Reported DRA HCA Measures on the CMS website.

The Missouri Hospital Association’s Statewide Patient and Family Advisory Council is now accepting applications for the fifth annual Compass Honor recognition. This award recognizes individuals and teams at Missouri hospitals who have demonstrated exceptional commitment to improving patient engagement, experience, and outcomes through innovative programs and initiatives.

This important honor recognizes Missouri hospitals for outstanding efforts in successfully engaging and integrating a PFAC throughout their organization. By recognizing a model PFAC, MHA encourages the adoption of PFAC best practices that improve the health care experience for patients and providers.

Two Compass Honors will be awarded based on hospital size — one for small hospitals with less than 100 beds and a second for larger hospitals with 100 beds or more. To apply, please complete the online application by Tuesday, Aug. 18.

The selected hospitals will receive a plaque, press kit and an on-site celebration to share this prestigious recognition. View past Compass Honor awardees at MoHospitals.org.

Age-friendly measures are designed to help hospitals deliver safer, more reliable care for older adults by aligning treatment with what matters to patients, improving medication management, and addressing risks such as frailty, delirium, falls and social vulnerability.

The Missouri Hospital Association developed the “CMS Age-Friendly Hospital Measure: Compliance Guide,” in which hospitals can review the measure domains, suggested ways to meet the measure as well as quick tips for implementation.

MHA established its Quality and Safety Committee, made up of clinical and operational leaders from Missouri’s hospitals and health systems, in the fall of 2025 and convened the first in-person meeting in March 2026.

The committee’s purpose is to guide and align quality and safety improvement efforts for hospitals around the state and build off the work of two former MHA committees — the Strategic Quality Advisory Committee (established in 2014) and the Health Equity Committee (established in 2020).

“Aligning the work of both committees under one effort is creating greater collaboration for members and their care teams as inpatient quality improvement and community-facing health improvement efforts overlap,” said Jackie Gatz, MHA’s senior vice president of quality, safety and research.

A Focused, Strategic First Year

MHA’s Quality and Safety Committee will prioritize the following focus areas in the first year:

• establish and monitor quality key performance indicators that align with MHA’s 2026-2028 strategic plan
• identify variations in care — using available data resources by geography, population and care setting — to develop hospital-centric interventions aimed at reducing variations in care, addressing nonclinical risk factors and improving health
• guide data-driven discussions that include developing board-level templates as well as supporting compliance, transparency and peer benchmarking
• promote a culture of safety through education and shared learning
• evaluate new care delivery models to support care coordination, improve health and reduce costs
• leverage established MHA committees, grant-funded work plans and existing hospital initiatives to enhance committee goals

The committee’s work is centered on data and the environment in which Missouri hospitals deliver care.

“This includes trends we can glean from claims data reported through the Hospital Industry Data Institute and quality improvement process measures collected through the National Healthcare Safety Network, as well as new and emerging regulatory requirements,” said Shephali Wulff, D.O., system vice president and chief quality officer at SSM Health and committee chair. “For example, with direction from the committee, staff will evaluate hospital performance against Centers for Medicare & Medicaid Services’ Star Ratings to support member quality strategy and improvement efforts.”

Once the framework for the key performance indicators is finalized, the committee will guide staff in prioritizing specific quality-improvement resources and member-engagement opportunities.

Collaborative Work

A core strength of the Quality and Safety Committee is its connection to the work already happening across Missouri’s hospitals and within MHA’s Quality, Safety and Research division.

In addition to reporting updates to the MHA Board of Trustees and developing templates for member hospitals to provide to their boards, the committee will collaborate closely with MHA groups such as the Maternal-Child Learning and Action Network, Patient and Family Advisory Council and Diabetes Shared Learning Network.

“These work groups will advance committee discussion and inform committee strategies that strengthen alignment among established, complementary efforts,” said Jenna Hicks, MBA, BSN, B.S., R.N., director of quality and population health at Citizens Memorial Hospital in Bolivar, Mo., and vice chair of the committee.

MHA will support member hospitals through technical assistance and educational offerings based upon the committee’s guidance. Quality leaders from Missouri hospitals can expect committee updates, as appropriate through MHA’s quality and safety newsletter. Not currently receiving this publication? Subscribe by contacting Jada Schwartz at jschwartz@mohospitals.org.

These findings reinforce that patient safety depends on strong leadership, transparent reporting and a culture of learning — not just technology. As the Centers for Medicare & Medicaid Services implements updates to the Patient Safety Structural Measure, Missouri hospitals can leverage the Missouri Hospital Association’s tools, education and Patient Safety Dashboard to strengthen safety systems and reduce preventable harm statewide.

Learn more about the training, including session links and full agendas, by viewing the 2026 PSC Annual Training Attendee’s Guide.

The NHSN PSC Annual Training began March 17 and will continue until Thursday, April 9. Live sessions are held Tuesdays and Thursdays from 11 a.m. to 3 p.m. All training sessions will be recorded and made available online at a later date.

In addition, the Missouri Hospital Association recently updated its PSSM page, which provides background information, definitions and resources to support hospitals with PSSM implementation.

Project Firstline’s “EVS Micro-Learns: Essentials for Infection Control” is a series of guided infection control discussions that provide brief, on-the-job training for EVS workers in health care settings. Each micro-learn explains how and why EVS practices help protect patients and save lives. 

New topics include the following.

• Clean and Safe Carts
• Clean Hands
• Contact Time
• Effective Cleaning and Disinfection Start With Preparation
• Sink Drains
• Water in Health Care 

Each micro-learn includes a user guide, discussion guide, and job aid, making the training easy for health care leaders to use and adapt for their teams. 

Project Firstline also offers other educational materials to support training on a range of infection control topics. 

“We created this guide to give hospitals an easy-to-use resource that simplifies an increasingly complex reporting landscape,” said Karie Untiedt, MHA’s director of quality and patient safety.

MHA aims to ensure every hospital, regardless of size or type, has the tools needed to accurately report quality measures and ultimately strengthen patient care across Missouri.

Accurate reporting remains essential to ensure patients are receiving high-quality care. In addition, the Centers for Medicare & Medicaid Services and other health care partners use quality measures in different initiatives for quality improvement, pay-for-reporting and public reporting. As a result, quality reporting directly impacts hospital reimbursements and financial stability.

“Precise quality measure reporting is essential to identifying opportunities for improvement, strengthening patient outcomes and sustaining high-quality care,” Untiedt said. “Because many measures are tied to regulatory requirements and value-based payment programs, accurate reporting also impacts compliance and financial stability, allowing hospitals to reinvest in staffing, technology and services that directly enhance patient care.”

Quality reporting programs influencing inpatient, outpatient and post-acute care are included in this guide. Additionally, the guide outlines which measures are required, which are voluntary, and how each affects payment, accreditation or public reporting.

The 2026 Quality Reporting Guide helps quality teams at Missouri’s hospitals identify what to report, determine when to report it and know which systems to use. The reporting guide will be updated as final rules or program requirements change, and members will be notified of all updates.

Developed with guidance from MHA’s Quality, Safety and Research team, the dashboard equips hospitals with timely, actionable insights that support both day-to-day improvement and long-term strategic planning.

What The Patient Safety Dashboard Helps You Do

• Benchmark with like-typed hospitals: Compare performance with peer facilities across Missouri, including the new domain structure introduced with the CMS Patient Safety Structural Measures announced for 2026.
• Monitor key patient safety indicators in real time: Track trends, identify variation and find opportunities for improvement using intuitive, Tableau-based visualizations.
• Strengthen Missouri advocacy efforts: Aggregated insights help MHA identify emerging patterns and advocate for resources that support hospital-led safety initiatives.
• Support compliance and continuous improvement: Data-driven insights help teams stay aligned with CMS requirements while advancing internal quality and safety goals.
   

Why This Matters Now

The updated CMS Patient Safety Structural Measures introduced a new domain for peer benchmarking making it even more important for hospitals to understand how their performance compares with similar organizations. The Patient Safety Dashboard incorporates this capability, giving members a clear view of where they stand and where improvement efforts can have the greatest impact.

Accessing the Dashboard

The Patient Safety Dashboard is available to all MHA members at no cost. Users can access their hospitals’ dashboard by signing in to the HIDI Advantage User Portal through Care Optics. Members who need access may request it.

Beginning Jan. 1, 2027, TJC will adopt the NQF’s updated SRE List as part of the SE List. This will allow accredited organizations to make required changes during this transition.

“Aligning Patient Safety Event Reporting” is a report published by the two organizations, detailing updates and including specific application guidance to enable more standardized implementation and thereby, allow meaningful comparisons across states, systems and even countries. A crosswalk of the SREs and the corresponding SEs is available to help health care organizations prepare for the transition.

To ensure workplace safety remains a priority, three workplace safety events from the legacy SE List — homicide, sexual abuse/assault and physical assault of a staff member — will be retained.

TJC and the NQF will host a patient safety capstone webinar that will cover the updates to SREs from noon to 1:15 p.m. Tuesday, March 3.

Of note, all immunizations recommended by the CDC as of Dec. 31, 2025, will continue to be covered by Affordable Care Act insurance plans and federal insurance programs including Medicaid, the Children’s Health Insurance Program and the Vaccines for Children program.

The CDC will publish an updated Child and Adolescent Immunization Schedule by Age for health care providers. Other organizations publish their own vaccine recommendations. Some mirror CDC recommendations while others differ, such as the American Academy of Pediatrics’ Recommended Child and Adolescent Immunization Schedule. Providers should review their chosen schedule(s) for potential gaps in private, ACA and federal insurance program coverage that could impact their patients.

• Missouri reported 8,986 flu cases (up from 5,876).
• Hospital admissions rose to 384 (up from 111).
• Influenza‑like illness accounted for 11.1% of emergency department visits (baseline: 2.4%).

MHA is monitoring these trends and will share updates as needed.

With respiratory virus activity rising, hospitals are urged to review their status and make appropriate updates and maintain situational awareness in the seasonal RVI Operational Impact Status in EMResource. Accurate, timely reporting helps identify operational challenges early and ensures hospitals receive appropriate support.

Children’s Mercy Kansas City 

Since 2003, Children’s Mercy Kansas City’s Family Advisory Board has partnered with hospital leadership to shape policies, programs and practices rooted in patient-and family-centered care.

This year, the FAB advanced initiatives to improve emergency department flow and experience, enhance the electronic medical record with patient input, and refine clinical pathways to embed family perspectives in care decisions. By aligning FAB engagement with strategic priorities, the hospital ensures patient and family voices drive meaningful change.

Golden Valley Memorial Healthcare – Clinton, Mo.

Established in 2016, Golden Valley Memorial Healthcare’s PFAC invites members to champion annual “passion projects.” This year, one member led an effort to address social isolation and caregiver burnout, partnering with hospital staff to create assessment tools, expand screening and launch an awareness campaign. Another member highlighted limited English proficiency as a barrier to care, prompting the hospital to strengthen identification processes and expand interpreter resources. Since then, use of interpretive services has increased 350%.

Denise Wilson, DNP, R.N., received the Distinguished Quality Professional Award from MHA's Missouri Association for Healthcare Quality for her leadership in elevating quality, safety and regulatory performance across SSM Health’s 23 hospitals and 350-plus clinics. She has advanced a culture of high reliability by building systemwide processes to identify gaps early, drive root-cause analysis and ensure sustained improvement.

Wilson helped design and deploy SSM Health’s Comprehensive Assessment Framework, a proactive model that continuously evaluates compliance with regulatory and evidence-based standards. She also contributes to statewide and national quality efforts through service on The Joint Commission’s Health System Advisory Council, Missouri’s Time Critical Diagnosis policy work, and MHA’s Regulatory, Survey and Licensure Advisory Committee.

Lean Six Sigma green belt and black belt certification programs are offered at a reduced cost through A3 Solutions Group to employees of Missouri hospitals.

Lean Six Sigma certification combines live, real-time (virtual) training courses and individualized coaching sessions as participants move through the phases of DMAIC: Define, Measure, Analyze, Improve and Control. Throughout the course, students will apply the knowledge and skills learned in trainings as they work on a required hospital-based improvement project.

MHA is accepting all applications. Additional weight will be given to the applications with a project focus on improving care delivery, reducing cost or eliminating waste with a focus on workflow-based areas.

Suggestions include Computerized Provider Order Entry (CPOE), barcode medication administration scanning compliance, reduction of medication errors, eliminating surgical/procedural harm, or reducing falls, Hospital Acquired Pressure Injuries (HAPIs), and infections.

Sponsored by the International Association for Healthcare Security and Safety, this observance highlights the dedication, professionalism and courage of those who protect health care facilities every day. 

MHA equips hospital safety leaders, facility managers and health system administrators with the resources, including the Healing Happens Here toolkit, they need to create and maintain safe, compliant environments for all. Learn how MHA helps hospitals create safe work environments. 

Health care public safety and security officers are often the first responders to emergencies, workplace violence incidents and safety concerns. Their work ensures that caregivers can focus on healing, patients can feel secure, and visitors can trust the safety of hospitals and health system facilities. In an era of increasing workplace violence and evolving security challenges, their commitment is more important than ever.  

Health care providers should include this infection in their diagnostic considerations for patients presenting with symptoms and track WNV activity on the DHSS website. 

The schedules will be updated on the CDC website by Tuesday, Oct. 7.

Building on a strong foundation, the academy model will continue to deliver essential orientation content in emergency preparedness, infection prevention and quality leadership, while expanding opportunities for learning and professional growth.

The new framework adds flexibility to cover additional safety-related fields, provide timely training on emerging issues and tailor sessions to member needs. 
 
The academy model will: 

• ensure consistent, high-quality orientation across disciplines,
• create a clear pathway for ongoing learning beyond orientation,
• introduce specialty and emerging-topic sessions as needed, and
• support members in building expertise and leadership capacity. 

More details on enrollment, curriculum tracks and session dates will be shared soon. 

With the launch of the Centers for Medicare & Medicaid Services’ Patient Safety Structural Measure, hospitals are reevaluating their approaches to fostering and maintaining a culture of safety.

One resource that hospital teams may find helpful is the TeamSTEPPS system — a strategic framework that aligns seamlessly with the expectations of the PSSM.

“Rather than reinventing the wheel, hospitals should view TeamSTEPPS as a foundational tool for meeting PSSM requirements,” said Jessica Stultz, Missouri Hospital Association’s director of clinical quality.

What are the five PSSM domains?

Since Jan. 1, CMS has required hospitals participating in the Hospital Inpatient Quality Reporting program to report on PSSM. Acute care hospitals paid by Medicare under the Inpatient Prospective Payment System are required to report on PSSM, while the program is voluntary for critical access hospitals.

The PSSM is designed to assess whether hospitals have robust systems and a culture that prioritizes patient safety. Hospitals must attest to their practices across the following five key domains.

1. leadership commitment to eliminating preventable harm
2. strategic planning and organizational safety
3. culture of safety and learning health systems
4. accountability and transparency
5. patient and family engagement

A breakdown of the PSSM’s five domains and their metrics is available here.

How does TeamSTEPPS align with PSSM?

Developed by the Agency for Healthcare Research and Quality and the U.S. Department of Defense, TeamSTEPPS equips health care teams with essential competencies in the following areas:

• communication
• leading teams
• situation monitoring
• mutual support

“Patient safety experts agree that communication and these other teamwork skills are essential to the delivery of quality health care and to preventing and mitigating medical errors and patient injury and harm,” said Karie Untiedt, MHA’s director of quality and patient safety.

The competencies learned in TeamSTEPPS directly support the PSSM standards.

• Effective team leadership ensures that safety is prioritized at all levels. Leaders trained in TeamSTEPPS model proactive behaviors, set clear expectations and foster accountability, all of which align with the CMS requirement for senior leadership and board oversight.
• TeamSTEPPS promotes standardized tools that help ensure alignment and clarity when developing and executing policies related to patient safety. Leading teams also involves engaging stakeholders in planning processes that reflect safety as a core value, supporting the goal of zero preventable harm.
• A learning health system thrives on situation monitoring, where team members continuously assess the environment, patient status and team functioning to identify risks early.
• Mutual support encourages a culture where team members speak up about concerns and reinforces psychological safety among care teams. Mutual support also promotes open dialogue and shared responsibility for outcomes, which aligns with the CMS emphasis on transparent data sharing and event reporting.
• TeamSTEPPS promotes patient-centered communication, ensuring that patients and caregivers are informed, heard, and involved in decision-making and safety activities.

How can MHA assist hospitals with TeamSTEPPS or PSSM?

Several MHA staff have been awarded TeamSTEPPS master trainer status and are available to visit and further discuss this innovative program. Contact Jessica Stultz to connect with these experts.

Building on this commitment to quality and safety, MHA subject matter experts earlier this year collaborated with patient safety professionals to host a three-part educational series on the CMS PSSM.

This series offered a detailed overview, which included domain interpretations as well as tools and suggestions on how to meet the metrics. The full series is available on-demand for those who wish to learn more.

To further support hospitals in their quality improvement efforts and compliance with CMS PSSM, MHA and its data company, the Hospital Industry Data Institute, offers the Patient Safety Dashboard.

Developed with stakeholders from MHA’s Quality, Safety and Research department, the dashboard is complimentary for MHA members. Users can access their personalized, Tableau-based dashboard via Care Optics® by signing into the HIDI Advantage^® user portal or requesting access.

MHA’s Statewide Patient and Family Advisory Council now is accepting applications for the fourth annual Compass Honor recognition. This award recognizes individuals and teams at Missouri hospitals who have demonstrated exceptional commitment to improving patient engagement, experience, and outcomes through innovative programs and initiatives.

This important honor recognizes Missouri hospitals for outstanding efforts in successfully engaging and integrating a PFAC throughout their organization. By recognizing and spotlighting a model PFAC, MHA works to encourage the adoption of PFAC best practices and advance the health care experience for patients and providers.

This year, two Compass Honors will be awarded based on hospital size — one for small hospitals with less than 100 beds and a second for larger hospitals with 100 beds or more. To apply, please complete the online application by Monday, Sept. 8.

The selected hospitals will receive a plaque, press kit and an on-site celebration to share this prestigious recognition. View past Compass Honor awardees at MoHospitals.org.

When it comes to ensuring that a hospital’s policies, procedures and daily operations are aligned with the needs and perspectives of those they serve, no one offers better insights than the patients and families who experience the care firsthand.

That’s the driving force behind Patient and Family Advisory Councils — collaborative groups that ensure patients’ and families’ voices are heard and acted upon in hospitals and health systems.

We asked members of Missouri Hospital Association’s statewide PFAC about the importance of PFACs and how they’ve benefited their hospitals, patients and communities.

“The purpose of PFACs in health care is to improve care by involving patients and families in decisions, ensuring their voices help shape policies, programs and services,” said Amber Lashley, director of patient experience at MU Health Care in Columbia, Mo.

Rachel Boyles, chief ancillary officer at Golden Valley Memorial Healthcare in Clinton, Mo., agreed, noting that PFAC members “are the eyes and ears of the community and utilizers of our services.”

At their core, PFACs are built on a simple but powerful concept: ask patients and families what matters to them and then use that feedback to guide improvements in care and operations.

Through these committees, patients and family members share their experiences and ideas with staff, nurses and doctors to address issues in specific care areas and to help inform hospital staff about ways to improve, Lashley said.

Why every hospital needs a PFAC

PFACs are essential for hospitals striving to deliver patient- and family-centered care.

“Every hospital should have a PFAC because every hospital exists to serve patients,” said Hope Bingham, patient experience project specialist with BJC Health System.

When hospitals design processes and improvements for patients, “the best way to ensure that these changes will actually improve the way we deliver care is to ask for feedback from the consumers or users of our health care services,” Boyles said. “PFAC is that go-to group.”

Through PFACs, health care leaders and providers have a ready-made platform to receive feedback from those directly affected by their care, leading to continuous improvement and enhanced patient satisfaction.

PFACs also can help foster mutual learning and collaboration between health care staff and patients. Leaders and employees at hospitals not only gain valuable insights when patients and families share their health care experiences, but also patients and families learn about the goals and challenges faced by hospitals.

Boyles said working with her hospital’s PFAC has changed her perspective on patient care, operations and more.

“My first thought now before changing a process is ‘how does this impact the patient?’ and ‘when is the next PFAC meeting so that I can obtain feedback before I proceed?’” Boyles said.

Sometimes, creating processes make sense to health care workers, but those processes may not always be what’s best for the patients, she said.

Turning insights into action

Hospitals that make PFACs a true partner in decision-making gain a valuable tool for improving the patient experience.

Feedback from these groups can shape everything from care delivery to educational materials to hospital policies. “Incorporating the feedback of your patient advisers early and often can save your organization from making costly mistakes,” Bingham said.

At GVMH, Boyles said the hospital’s PFAC now is an integrated part of the organization’s strategic planning process and ongoing strategic planning implementation. “This has caused our leadership and executive teams to be more consumer focused with process improvements and innovation design,” she said.

At Children’s Mercy Kansas City, Sheryl Chadwick, program manager for patient and family engagement, said the hospital’s PFAC created a video that is shown for all new employees explaining the principals of patient- and family-centered care and how employees have the opportunity to make a positive difference in every patient’s day.

PFAC members at Children’s Mercy also participate in Grand Rounds, sharing their experiences and contributing to discussions on patient care. Additionally, the council developed videos, handouts and website information to offer guidance and support for families navigating hospital stays and the health care system.

Getting started with a PFAC

For hospitals that don’t yet have a PFAC, now is the time to start.

The Missouri Hospital Association offers numerous resources for Missouri hospitals, whether they are starting a new PFAC or have an existing PFAC, said Jessica Stultz, MHA director of clinical quality.

MHA’s statewide PFAC comprised of patients, family members, patient advocates, hospital staff and providers throughout Missouri. One of only a handful of state-level councils in the U.S., MHA’s PFAC is focused on increasing the role of patients and family members to improve health care delivery, health outcomes and more. To join the MHA PFAC, hospital staff can fill out a membership application.

Health care workers who would like to learn more about recruiting for a representative PFAC are invited to register for MHA’s virtual office hours session scheduled for Thursday, May 15.

MHA’s statewide PFAC also hosts an annual recognition — The Compass Honor, which recognizes a Missouri hospital for outstanding efforts in effectively partnering with their PFAC. Through public recognition, this honor encourages and inspires hospitals to adopt practices, learn collectively and improve their PFACs.

Additional resources, toolkits and support for PFACs include the Institute for Patient- and Family-Centered Care and The Beryl Institute.

To learn more about MHA’s statewide PFAC, the Compass Honor and resources for PFACs, contact Jessica Stultz.

The report found when health care leaders make creating a culture of safety their top priority, it greatly impacts patient safety outcomes, the patient experience, and workforce engagement and resilience.

“With all of the work being done in and around safety and workforce, it’s important to align the relationship between safety, staff retention and culture as one focus for hospitals and health systems,” said Karie Untiedt, R.N., MSN, director of quality and patient safety at the Missouri Hospital Association.

The report stated a culture of safety should include the following:

• an environment where anyone can speak up,
• confidence that improvements occur when issues are reported,
• fair and compassionate treatment when an error occurs, and
• effective teamwork and communication.

The report noted a culture of safety is so important that the Centers for Medicare and Medicaid Services has made it one of its five structural domain metrics.

As part of the fiscal year 2025 final rule, CMS is requiring hospitals participating in the Hospital Inpatient Quality Reporting program to report on the Patient Safety Structural Domain Metrics, which provide a way for hospitals to address a topic for which no outcome measure exists.

CMS’ five domains for measurement are:

1. leadership commitment to eliminating preventable harm,
2. strategic planning and organizational safety,
3. culture of safety and learning health systems,
4. accountability and transparency, and
5. patient and family engagement.

Patient Safety Dashboard

To support hospitals in improving patient safety and quality outcomes, MHA and the Hospital Industry Data Institute developed a new Patient Safety Dashboard within the HIDI Advantage Care Optics® Portfolio.

This complimentary, interactive tool provides key patient safety and quality metrics, benchmarking capabilities, and insights to help hospitals identify best practices. The dashboard also will enhance MHA’s advocacy efforts by identifying statewide resources needed to support hospital-led safety initiatives. 

Importance of teamwork

According to AHA’s patient safety report, across numerous clinical areas, the greatest factor of a patient’s likelihood to recommend a hospital, facility or provider is perception on how well their care team members work together.

“A key driver to improving the patient experience is the teamwork of caregivers,” Untiedt said. “Better teamwork leads to better outcomes, which leads to better experiences for both patients and staff.”

Health care staff interested in learning more about training opportunities that offer ways to improve collaboration and communication within their organization are encouraged to contact MHA about TeamSTEPPS, or Team Strategies and Tools to Enhance Performance and Patient Safety.

TeamSTEPPS is based on team structure and four learnable skills — communication, leading teams, situation monitoring and mutual support. The team structure includes everyone in the patient care team including patients, families, direct caregivers and all individuals who play a supportive role.

Workforce well-being

The AHA report also notes that investing in the well-being of a hospital’s workforce improves patient care. “An energized and engaged workforce improves the care provided to patients, the physical and psychological well-being of patients, and how patients perceive the work to keep them safe,” the report states.

MHA’s 2023 Workforce Report provides tips for hospitals to better care for and retain staff: “Health system leaders must normalize help-seeking behavior, provide mentorship to less experienced nurses, and build support systems and training to help leaders and staff identify and address well-being. Organizations not only must support team member resilience but give them a voice in addressing workflows and processes that may impede their work.”

MHA offers numerous resources on workforce well-being for hospital staff who want to learn more about this topic.

This saying is considered a core principle derived from the Hippocratic oath, historically taken by physicians to uphold ethical standards, that emphasizes avoiding harm to patients. Essentially, this phrase reminds health care providers and staff to put the patient's safety first.

Patient Safety Awareness Week, an annual recognition event that typically occurs during the second week in March, serves as a reminder that patient safety should be the No. 1 priority in health care.

Studies show that hundreds of thousands of preventable harm events occur each year in the U.S. that result in long-term adverse health effects, or even death.

“The key words here are ‘preventable harm’ that can be avoided, simply by identifying and addressing the cause,” said MHA Director of Quality and Patient Safety Karie Untiedt, R.N., MSN.

“Patient Safety Awareness Week is intended to encourage everyone to learn more about health care safety,” Untiedt said. “The week also is intended to raise awareness about identifying processes that could lead to preventable harm and celebrating the efforts already made, including by those who work quietly behind the scenes with the patient always in mind.”

Common preventable harm events

Understanding the most common sources of patient harm is essential for health care providers, administrators and policymakers to improve safety protocols and reduce risks.

Medication errors, patient falls, pressure injuries and health care-associated infections are some of the preventable harm events that can occur in hospital and clinical settings.

Safe hospitals and health systems adopt all necessary measures to avoid and reduce patient harm. Untiedt noted that everyone — from the board of trustees to the front-line staff — plays a role in advancing safe care.

“If I could offer hospital and health care workers one piece of advice on patient safety, it would be to create a culture where safety is the top priority,” Untiedt said. “There has to be a culture where all clinical and nonclinical staff are comfortable speaking up and involved in process improvements.”

Supporting patient safety efforts

The Missouri Hospital Association supports hospitals across the state in a variety of ways to improve patient safety and care quality.

One way MHA helps hospitals is through education and support to become high reliability organizations. Untiedt said an HRO embarks on a mission to commit to zero harm and realize true, purposeful work in health care.

Health care staff also can access TeamSTEPPS, or Team Strategies and Tools to Enhance Performance and Patient Safety, training through MHA. This training offers ways to improve collaboration and communication within your organization.

Health care professionals also can earn certifications through the Lean Six Sigma program.

Educational opportunity

The MHA Health Institute will host a three-part virtual educational series on March 11, March 18 and March 25 to provide a detailed overview of the CMS Patient Safety Structural Measures, which took effect Jan. 1, 2025. These measures are required for inpatient prospective payment system hospitals and voluntary for critical access hospitals.

Teaming up with quality and patient safety experts, Untiedt said MHA subject matter experts will share domain interpretations as well as tools and suggestions on how to meet the metrics during these sessions. This educational series is complimentary for MHA members.

New Patient Safety Dashboard

The Hospital Industry Data Institute, in mission-aligned partnership with MHA, is dedicated to equipping hospitals with the tools and insights needed to enhance patient safety.

As part of this commitment, Brandon Hutchison, MHA’s senior vice president of research, data and information services, said HIDI will launch a new Patient Safety Dashboard later this spring. The dashboard is a Care Optics® product offering that supports hospitals in meeting the new PSSM.

Hutchison said this interactive tool will provide hospitals with key patient safety and quality metrics, peer benchmarking capabilities, and insights to identify best practices. The dashboard also enhances MHA’s advocacy efforts by identifying statewide resource needs to support hospital-led safety initiatives.

A live demonstration of the dashboard’s features will be shared during the educational series. If you have any questions about gaining access to the dashboard, please contact Linda Bell.

Resources

For more information about patient safety, check out these resources.

• Agency for Healthcare Research and Quality
• AHA Patient Safety Initiative
• CMS Blog: First, Do No Harm
• Institute for Healthcare Improvement: Patient Safety Awareness Week
• Missouri Association for Healthcare Quality

“Every hospital aspires to deliver the best possible care while creating an environment that supports healing,” said MHA President and CEO Jon D. Doolittle. “The science of care delivery advances constantly. However, to learn about the environment of care, hospitals rely heavily on input from patients, families and communities.”  

Hospitals establish Patient and Family Advisory Councils to understand how patients experience their care. These PFACs help hospitals identify opportunities for improvements in environment, where systems and processes complicate the health care experience, and how to foster better communication and engagement with patients.   

Harrison County Community Hospital received the Compass Honor for a hospital with fewer than 100 beds.  

Since the hospital PFAC’s initial meeting in January 2024, members have offered input on many initiatives such as renovating a waiting room, streamlining discharge paperwork, expanding community health fair offerings and improving accessibility options during registration. 

“Our Patient and Family Advisory Council is pivotal in transforming our acute appointment scheduling and waiting room experiences,” said Tara Sherer, CNA, PFAC Chair and Director of In-Home Services and Registration at Harrison County Community Hospital. “By prioritizing innovations like negative air systems, enhanced registration options for those who are hard of hearing and thoughtful accessibility measures, we’re not just improving logistics — we’re fostering an environment where every patient feels safe, heard and valued. Together, we’re redefining care for a healthier tomorrow.” 

Additionally, the council supported a telehealth grant, served as “secret shoppers” for infection control, assisted with tracking outpatient clinic wait times, offered autism resources, provided feedback for a new stroke support group and collaborated with the patient experience team to drive patient-centered improvements at HCCH. 

BJC HealthCare earned the Compass Honor as an organization with more than 100 beds. The health system’s Sickle Cell Patient, Family, Community Advisory Council has helped guide improved care coordination systems for BJC’s sickle cell disease patients. The council offered feedback on proposed workflows, accessibility of space and design of the Sickle Cell Treatment Center at Barnes-Jewish Hospital — the first comprehensive adult treatment center for sickle cell disease in the St. Louis region.  

“The Sickle Cell Patient, Family, Community Advisory Council has served as an integral part of the development of improved care coordination for sickle cell patients throughout BJC,” said Winston Wright, Program Manager of Diversity, Equity and Inclusion at BJC HealthCare. “Six of the seven members of the council volunteered their time over the course of a year to meet with hospital executives, physicians and other staff to share their experiences. As solutions began to be identified, we formed the council so that the members could have a formal role in strategic planning and operationalization.” 

The council’s work has helped to normalize the needs of sickle cell patients at BJC, and the input that members offered have helped to begin closing gaps in care to this patient population.  

Two hospitals were named runners-up in the Compass Honor. Golden Valley Memorial Healthcare in Clinton, Mo., was named a runner-up for an organization with fewer than 100 beds, while North Kansas City Hospital was honored as an organization with more than 100 beds.  

In 2022, MHA introduced the Compass Honor, which is sponsored by the Statewide PFAC. To learn more about this annual recognition and read about previous Compass Honor recipients, visit MHA’s PFAC webpage.