Monthly Newsletter

December 2024 Monthly Newsletter

Joint Commission 2025 National Patient Safety Goals
ASTP on Health IT to Improve Patient Safety
Advancing Health Care Safety

Clinical Decision Support Promotes Patient Safety
2025 Electronic Clinical Quality Measure (eCQM) Specifications

Joint Commission 2025 National Patient Safety Goals

Joint Commission has posted their national patient safety goals for 2025, which we have listed below with hyperlinks for easy access:

ASTP on Health IT to Improve Patient Safety

“Patient safety” refers to freedom from accidental or preventable injuries associated with healthcare services. Your electronic health record (EHR) system provides tools to help clinicians improve patient safety. EHRs play an integral role in larger systems composed of the clinical team, the patient, and the daily supporting workflows. When analyzing EHR safety, be sure to consider the entire system as a whole.

The Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP) provides SAFER Guidelines which consist of nine guides organized into 3 broad groups: Foundations, Infrastructure and Clinical Process. The guides identify recommended practices to optimize the safety and safe use of EHRs. Most organizations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern. Learn More and Access the SAFER Guides.

Advancing Health Care Safety

CMS National Quality Strategy

As the largest payer of health care services in the United States, serving over 160 million Americans, the Centers for Medicare & Medicaid Services (CMS) is committed to reducing patient harm and promoting a culture of safety for patients nationwide.

Key Actions to Improve Health Outcomes and Health Care Quality:

Drive improvements on high-priority outcomes. CMS operates quality reporting and value-based payment programs and alternative payment models to promote accountability through payment and public reporting for safe, high-quality care for all. These programs, along with the Quality Improvement Organization (QIO) Program, catalyze quality efforts on the most pressing health topics, such as behavioral health, maternal health, long-term services and supports (LTSS), and oral health.
Leverage quality measures to improve health outcomes. Quality measures are a key tool for CMS to identify opportunities for improvement and evaluate progress. CMS is shaping a measure ecosystem that focuses on improving outcomes, driving value-based care, and reducing provider reporting burden.
Set benchmarks to track progress. Clear targets and increased reporting transparency help CMS advance improvement efforts around a shared objective. CMS conducts a triennial assessment of quality measures used across its programs to monitor clinical improvements and track progress on narrowing disparities.

In November, 2024, CMS published key actions to promote zero harm for all – Click Here for more information from CMS. Download the CMS Framework for Advancing Health Care in Rural, Tribal, and Geographically Isolated Communities Report.

The American Institute of Healthcare Compliance (AIHC) is a licensing/certification partner with CMS. Consider taking the $75 AIHC online training Quality, Root Cause Analysis (RCA) & the 8D Approach – Short Course.

Clinical Decision Support Promotes Patient Safety

Clinical decision support (CDS) can significantly impact improvements in quality, safety, efficiency, and effectiveness of health care. Overall, as technology advances and healthcare data becomes more readily available, CDS has the potential to significantly enhance patient safety by providing timely, relevant information to clinicians at the point of care, enabling better decision-making and preventing preventable errors.

CDS is expected to play a significant role in promoting patient safety by 2025, primarily by providing real-time, evidence-based alerts and recommendations within the electronic health record (EHR), which can help clinicians identify potential risks, prevent medication errors, and make informed decisions at the point of care, ultimately leading to improved patient outcomes and reduced adverse events.

CDS is a sophisticated health IT component. It requires computable biomedical knowledge, person-specific data, and a reasoning or inferencing mechanism that combines knowledge and data to generate and present helpful information to clinicians as care is being delivered. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include:

Computerized alerts and reminders to care providers and patients;
Clinical guidelines;
Condition-specific order sets;
Focused patient data reports and summaries;
Documentation templates;
Diagnostic support, and contextually relevant reference information, among other tools.

Resources to learn more –

Article from the National Institutes of Health Harnessing the power of clinical decision support systems: challenges and opportunities
Agency for Healthcare Research & Quality (AHRQ) webpage Clinical Decision Support

2025 Electronic Clinical Quality Measure (eCQM) Specifications

eCQMs are measures specified in a standard electronic format that use data electronically extracted from electronic health records (EHR) and/or health information technology (IT) systems to measure the quality of health care provided. CMS eCQMs measure many aspects of patient care, including:

Patient and Family Engagement
Patient Safety
Care Coordination
Population/Public Health
Efficient Use of Healthcare Resources
Clinical Process/Effectiveness

Health care providers are required to electronically report eCQMs, which use data from EHRs and/or health information technology systems to measure health care quality. To report eCQMs successfully, health care providers must adhere to the requirements identified by the CMS quality program in which they intend to participate.

Important to the development of eCQMs is the use of value sets. Value sets contain lists of codes and corresponding terms used by developers and implementers to accurately capture patient data in the EHR system. CMS has published Value Set Guidance to help developers in the design and maintenance of value sets, including areas of naming, description, content choice, and harmonization.

Value set guidance can be viewed under the Resources menu of the Electronic Clinical Quality Improvement (eCQI) Resource Center. Click Here for more information on the 2025 eCQM specifications.