Quality and Patient Safety | MedStar Institute of Quality and Safety | MedStar Health

MIQS toolbox

In the rapidly changing healthcare environment, quick and easy access to usable tools and resources is becoming imperative. This page provides open-source information related to quality metrics and programs, quality improvement tools, patient and family engagement in patient safety and communication, and resolution programs.

Quality metrics, programs, and oversight 

CMS Measures Inventory

The CMS quality measures inventory is a compilation of measures used by CMS in various quality, reporting, and payment programs. The Inventory lists each measure by program, reporting measure specifications including, but not limited to, numerator, denominator, exclusion criteria, meaningful measures domain, measure type, and National Quality Forum (NQF) endorsement status.

CMS: Overall Hospital Quality Star Ratings on Hospital Compare

-This presentation educates participants about the methodology used to generate the summary five-star rating for individual hospitals using existing measures on hospital compare, as well as changes to the July 2016 preview reports and SAS pack distribution. [05/12/2016]

CMS: Hospital VBP: FY 2018 Percentage Payment Summary Report

This event provides an overview of the Fiscal Year (FY) 2018 Hospital Value-Based Purchasing (VBP) Percentage Payment Summary Report (PPSR), including: how hospitals are evaluated within each domain and measure; how the Hospital VBP Program scoring methodology is reflected in the report; and what constitutes eligibility for the Hospital VBP Program. [07/24/2017]

CMS: Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) Final Rule: Acute Care Hospital Quality Reporting Programs Overview

-This presentation provides participants with the FY 2018 Hospital IPPS for acute care hospitals final rule. This discussion addresses the Final Rule’s impact on the following programs: •Hospital Inpatient Quality Reporting (IQR) Program •Hospital Value-Based Purchasing (VBP) Program •Hospital-Acquired Condition Reduction Program (HACRP) •Hospital Readmissions Reduction Program (HRRP) [08/29/2017]

HSCRC: performance measurement workgroup information - meeting materials

This workgroup develops recommendations for the HSCRC on measures that are reliable, informative, and practical for assessing a number of important issues.

Framework for effective board governance of health system quality

-The IHI Lucian Leape Institute has produced a new framework for effective board governance of health system quality. MIQS Advisory Board member, Beth Daley Ullem is a lead author. The framework was developed to reduce variation in and clarify trustee responsibilities for quality oversight, and provide practical tools for trustees and the health system leaders who support them to govern quality that results in delivery of better care to patients and communities.

A suite of tools was published in 2018, including:

Framework for effective governance of health system quality: A clear, actionable framework for oversight of all the dimensions of quality.

Governance of quality assessment: A tool for trustees and health system leaders to evaluate and score current quality oversight processes and assess progress in improving board quality oversight over time. (Online tool also available.

Three support guides: Three central knowledge area support guides for governance of quality (Core Quality Knowledge, Core Improvement System Knowledge, and Board Culture and Commitment to Quality), which health system leaders and governance educators can use to advance their education for trustees.

The advancing governance of quality: Bedside to Boardroom video series, six brief 5-8-minute video episodes highlight different learning scenarios for trustees to better understand quality from a patient-centered point of view and the trustee’s role in overseeing quality in the health system. The videos complement the white paper from IHI/LLI entitled: Framework for Effective Board Governance of Health System Quality and demonstrate the central tenets for Governance of Health System Quality.

Quality improvement tools

The MedStar Institute for Quality and Safety has assembled a collection of publicly available resources to assist healthcare organizations with their improvement initiatives. These are videos that have been viewed and used by Quality & Safety staff within the Institute and deemed to be of value to other Quality & Safety Professionals who are looking for quick resources that can be easily shared.

 Category  Resource
 Driver Diagrams
 Plan Do Study Act (PDSA)
 Lean & Six Sigma
 Process Mapping
 Root Cause Analysis
 Logic Models
 Failure Mode and Effects Analysis
 Fishbone Diagram

Quality reporting websites

Hospital Compare

-Hospital Compare is part of the Centers for Medicare & Medicaid Services (CMS) Hospital Quality Initiative. The Hospital Quality Initiative uses a variety of tools to help hospitals improve the quality of care they deliver. The aim is to help improve hospitals’ quality of care through easy-to-understand data on hospital performance, and quality information from patient perspectives.

Hospital Quality Measures

-Quality measures were developed by the Centers for Medicaid and Medicare Services (CMS) as a tool for assessing how well a hospital is providing care and medical services for its patients. The collection and reporting of these quality measures help providers ensure that their patients are receiving effective, efficient, and safe care. These measures are publicly reported to help consumers see how hospitals in their area are performing and to select which hospital could best fit their needs.

U.S. News & World Report Hospitals Rankings and Ratings

-The U.S. News & World Report Hospitals Rankings and Ratings Best Hospitals analysis reviews hospitals' performance in clinical specialties, procedures, and conditions. Scores are based on several factors, including survival, patient safety, nurse staffing, and more. Hospitals are ranked nationally by specialty, from cancer to urology, and rated in common procedures and conditions, such as heart bypass surgery, hip and knee replacement, and COPD. Hospitals are also ranked regionally within states and major metro areas.


-Healthgrades is a US company that provides information about physicians, hospitals, and healthcare providers. Healthgrades has amassed information on over 3 million U.S. healthcare providers.

Leapfrog Group

-The Leapfrog Group is a nonprofit watchdog organization that serves as a voice for healthcare purchasers, using their collective influence to foster positive change in U.S. healthcare. Leapfrog is the nation’s premier advocate of hospital transparency—collecting, analyzing, and disseminating hospital data to inform value-based purchasing.


-WhyNotTheBest.org is a free resource for healthcare professionals interested in tracking performance on various measures of healthcare quality. It enables organizations to compare their performance against that of peer organizations, against a range of benchmarks, and over time. Case studies and improvement tools spotlight successful improvement strategies of the nation’s top performers. A regional map shows performance at the county, HRR, state, and national levels.

Consumer Reports Doctors & Hospitals guide

-Whether you're looking for a new doctor, deciding whether to have surgery, or learning how to stay safe in the hospital, Consumer Reports Doctors & Hospitals guide will show you the right questions to ask and how to get the critical answers you need.

Patient and family engagement

Resources for Patient and Family Engagement in Quality and Safety

AHRQ guide to PFE

-The guide to patient and family engagement in Hospital Quality and Safety is a tested, evidence-based resource to help hospitals work with patients and families to improve quality and safety. The Guide contains four evidence-based strategies to help hospitals partner with patients and families. For each strategy, there is an implementation handbook and tools for patients, families, and clinicians.

A leadership resource for patient and family engagement strategies

This resource was created by the Health Research & Educational Trust (HRET) and leverages the above AHRQ Guide to PFE along with other valuable resources to focus on the most important steps organizational leaders can take to effectively promote patient and family engagement.

MIQS-H2Pi PFACQS® 1.0 assessment tool

The purpose of this assessment tool is to develop baseline information the project team can use to thoughtfully develop a Patient and Family Advisory Partnership Council for Quality and Safety (PFACQS®) that (a) meets the needs of the healthcare organization; and (b) aligns with its mission, goals, culture, and strategies.

Partnership for Patients (PfP) Strategic Vision Roadmap for Person and Family Engagement (PFE)

Developed by American Institutes for Research (AIR), this document outlines CMS’ Partnership for Patients (PfP), a quality and safety improvement initiative to make hospital care safer, more reliable, and less costly. The resource provides strategies that can be applied to CMS’ five PFE metrics:

PFE1: Planning checklist for scheduled admission; PFE2: Shift change huddles/bedside reporting; PFE3: PFE leader or functional area; PFE4: PFAC or representative on quality improvement team; PFE5: Patient and family advisor on board.

Importance of Person and Family Engagement in Patient Outcomes

Person & Family Engagement (PFE) is now recognized as a method for reducing medical errors, falls, and hospital readmissions. In this video, Medstar Health’s Marty Hatlie explains what PFE is and the results that hospitals are seeing through this improvement.

Guide to improving patient safety in primary care settings by engaging patients and families

The guide is a resource to help primary care practices partner with patients and their families to improve patient safety. The guide is composed of materials and resources to help primary care practices implement patient and family engagement to improve patient safety. The project is led by the MIQS Research team.

Additional tools and checklists for implementing the five PFE CMS metrics are below:

 PFE Metric  Resource
 PFE Metric 1: Planning checklist for scheduled admission
 PFE Metric 2: Shift change huddles/bedside reporting
 Lean & PFE Metric 3: PFE leader or functional area
 PFE Metric 4: PFAC or representative on quality improvement team
 PFE Metric 5: Patient and family advisor on board

Resources for Implementing Patient and Family Advisory Councils

Patient and Family Advisory Councils Overview

-(15 min. PPT overview) - Patient and Family Advisory Councils (PFACQS) are a mechanism for embedding regular input and feedback into improvement work from the communities we serve. The Centers for Medicare & Medicaid Services and other payors are now driving patient and family engagement through advisory councils as a strategy to improve outcomes, reduce cost, promote transparency, and reinforce the joy and meaningfulness of healthcare work.

Starting a PFACQ

-This video provides practical advice from International PFE experts on how to start a PFACQ at your organization.

H2PI roadmap to success infographic

- MIQS partners with H2Pi.org

-MIQS partners with H2Pi.org to provide PFACQS consulting to other provider organizations in establishing their own PFACQS focused on preventing harm and continuously advancing quality. H2Pi’s unique “Road to Success” approach helps hospitals and healthcare systems strategize and prepare for implementation through a step-by-step pathway, developed through years of experience with hospitals and healthcare systems around the world.

Communication and resolution programs

Unexpected patient harm is far too common, and the response typically fails to meet the patient’s and family’s needs, or promotes learning that could prevent future harm. Communication and Resolution Programs (CRPs) are a principled approach for responding to patient harm. They are an integral component of an effective, empathic patient safety and quality improvement program, implemented for the benefit of patients, care professionals and our healthcare communities.

Agency for healthcare research and quality CANDOR toolkit - The CANDOR toolkit contains eight different modules, each containing PowerPoint slides with facilitator notes. Some modules also contain tools, resources, or videos.