OIG recommendations

In the report, OIG also outlined three recommendations for federal agencies, their partners, surveyors, and states to help better identify and reduce patient harm events:

1. Standardize definitions of harm events

In the report, OIG recommended that the Agency for Healthcare Research and Quality (AHRQ) and CMS lead a national effort to create standardized definitions of patient harm across the healthcare industry. OIG also recommended the agencies work with federal partners and other relevant organizations to create a taxonomy of patient harm.

"By aligning these definitions, AHRQ and CMS would be supporting hospitals' efforts to capture harm and would facilitate greater communication about the incidence of harm and safety practices within facilities and across the medical community," OIG wrote.

2. Have surveyors assess compliance with Medicare quality programs

In 2023, CMS released new interpretive guidance for surveyors on how to assess hospitals' compliance with the Medicare Quality Assurance and Performance Improvement (QAPI) requirement.

OIG recommended CMS take steps to ensure surveyors prioritize the QAPI requirement when they assess hospitals and hold them accountable for complying with the requirement. CMS should also encourage surveyors to adopt the new guidance for assessing hospitals' QAPI programs and use its oversight to ensure that surveyors are assessing hospital compliance with the requirement effectively.

3. Assist hospitals with incident reporting systems

Finally, OIG recommended CMS provide further guidance to Quality Improvement Organizations (QIOs) to help them determine whether hospitals captured harm events in their incident reporting or other surveillance systems. If hospitals are not capturing harm events, QIOs can help identify and address any potential weaknesses in the reporting systems.

CMS' guidance should also direct QIOs to assess whether hospitals investigated harm events and escalate the situation to hospital governing boards if appropriate. "This could help hospitals identify and mitigate barriers to making quality and safety improvements within their own systems," OIG wrote.

The case for system-wide care variation reduction

By Isis Monteiro and Mahaya Walker

The recent HHS OIG report on patient harm events underscores the importance of adopting a system-level approach to designing and implementing care standards. Specifically, a system-wide commitment to care variation reduction (CVR) can help standardize processes, align staff on harm event reporting, and ultimately prevent harm events from occurring. CVR can also be applied to address many other quality, safety, and cost challenges faced by health systems.

Historically, systems have struggled to achieve system-wide standardization because it requires executive commitment and investments to build foundational capabilities and infrastructure. Taking a system-wide approach to standardization is especially critical now given policy shifts that will impact health systems' finances amid structural shifts to the operating environment. To get ahead of these changes, health systems should prioritize strategies that can simultaneously improve quality, decrease costs, and support long-term business objectives — all of which are possible through CVR. 

Best in class systems typically establish a CVR governance structure that accounts for regional and local nuances when designing care standards, while also factoring in the workflows of clinicians who will put those standards into practice. Additionally, these systems offer centralized education, training, and implementation support to ensure consistent adoption and adherence to care standards across all facilities. The first steps toward improving patient safety and quality (while also supporting other business objectives) through system-level CVR is securing executive commitment and ensuring that health systems are well positioned to achieve their goals at scale.