The SAFER Guides were created by CMS as part of the Medicare Promoting Interoperability Program. They encourage safe use of certified electronic health record technology (CEHRT). Hospitals, critical access hospitals (CAHs), and clinicians who qualify for the Merit-based Incentive Payment System (MIPS) must complete these self-assessments every year.
There are nine parts of the guides, each focusing on different areas of EHR safety. These include things like medication reconciliation, clinician communication, and monitoring system safety. The guides help healthcare providers find risks in their EHR systems and fix them to keep patients safe. Hospitals and CAHs need to complete all nine guides every year. Clinicians in MIPS complete assessments related to High Priority Practices.
If a hospital or clinician does not complete or submit the assessments, they get a zero score for the SAFER measure. This can hurt their performance in CMS reporting programs. It may also reduce their payments and affect public reporting of quality results.
Administrative and Operational Challenges in Completing SAFER Guide Assessments
Finishing the SAFER Guide assessments is a detailed process that takes time. Hospital leaders and IT staff must work together to review safety, find risks, and plan fixes. Several problems make it hard to complete these assessments:
- Resource Limitations
Many hospitals, especially smaller CAHs, do not have enough staff or technology. Assigning people to manage these assessments may compete with other important tasks. Hospitals with tight budgets might have trouble making these assessments a priority over urgent needs.
- Complexity of EHR Systems
EHR systems are different across hospitals and often customized. It can be hard to understand all safety risks without strong technical skills. When staff lack this knowledge, it is tough to find risks and document good practices.
- Data Collection and Documentation
The SAFER Guides need detailed paperwork, like checklists and action plans. Gathering correct data from many departments takes coordination. This can disrupt staff work as time is spent collecting information.
- Timely Completion and Reporting
The deadline to finish and report the assessments is December 31 each year. Meeting this date is hard if hospitals have staff shortages, technical problems, or other urgent duties late in the year.
- Lack of Awareness or Training
Some hospitals do not fully understand why the SAFER Guides matter or what happens if they do not complete them. Limited training about how to finish the assessments or find CMS resources can prevent compliance.
Consequences of Not Completing the SAFER Guide Self-Assessments
Not completing the SAFER Guide self-assessment reports causes many problems for hospitals and CAHs:
- Financial Penalties and Loss of Incentives
Being part of the Medicare Promoting Interoperability Program links directly to getting money and reimbursements. Hospitals and CAHs that skip the SAFER Guides get a zero score. This lowers their overall performance scores in CMS programs and can reduce payments, cutting hospital income.
- Impact on Medicare and Medicaid Eligibility
Since the SAFER Guides are part of federal programs, not following the rules can hurt a hospital’s status with Medicare and Medicaid. Direct denial is rare, but ongoing non-compliance can damage trust and risk future participation.
- Patient Safety Risks
The main goal of the SAFER Guides is to lower risks in EHR use. If hospitals skip or do a poor job on assessments, they might miss safety problems like wrong medication orders, slow clinical communication, or wrong data. This puts patient safety at risk, going against healthcare goals.
- Regulatory Repercussions and Public Reporting
CMS requires hospitals to confirm yearly that SAFER Guides were completed. Saying “no” or failing to respond leads to public reporting of poor scores. This can hurt a hospital’s reputation with patients, insurers, and regulators.
- Operational Inefficiencies
Without doing SAFER assessments, hospitals lose chances to check and improve their work. The process helps find workflow or system problems. Without it, these issues stay, which can cause more mistakes and higher costs.
Role of AI and Workflow Automation in Managing SAFER Guide Requirements
Technology, especially AI and automation, can help hospital teams meet SAFER Guide rules more easily. AI tools can improve healthcare work including compliance tasks.
AI-Driven Workflow Automation for Assessment Management
Managing SAFER Guide assessments needs data collection, good communication among departments, and keeping track of deadlines. AI tools can:
- Automate Data Collection
AI can connect with EHR systems to collect live data on patient safety and system use. For example, it can help check medication accuracy or system alerts automatically, lowering manual work.
- Schedule and Manage Deadlines
Automated reminders can alert staff about coming deadlines, needed documents, and submission status.
- Improve Documentation Accuracy
AI tools can help turn clinical notes into checklist-ready formats. This reduces mistakes and helps make paperwork complete.
- Enhance Communication Across Departments
AI communication tools can help organize work between IT, clinical, and admin teams during assessments.
AI Support in Patient Safety Focus
AI also offers tools that directly improve EHR safety. These include decision support systems that warn about possible medication errors, tools that check data accuracy, and software that predicts system problems. Hospitals can use these AI tools to better handle safety issues noted in the SAFER Guides.
Specific Recommendations for Medical Practice Administrators, Owners, and IT Managers
Given the challenges and risks of not completing SAFER Guides, healthcare leaders should consider these actions:
- Invest in Training and Resources
Train staff about SAFER requirements and how to finish the assessments. Use resources provided by CMS, including help desk support.
- Leverage Technology Solutions
Use AI and automation tools to cut down manual work and improve data collection. Add automated workflows to keep the process organized.
- Develop Cross-Department Collaboration Plans
Set clear roles for clinical, administrative, and IT teams to make sure data and documents are complete and on time.
- Prioritize Annual Assessments
Include SAFER self-assessments in yearly hospital checklists. Avoid last-minute efforts that can cause errors or missing information.
- Seek External Support When Needed
Contact CMS help desks or the Quality Payment Program Service Center for help if trouble arises or deadlines are hard to meet.
In short, following SAFER Guide requirements is important for making EHR systems safer in hospitals and CAHs. Problems like complex systems, limited staff, and paperwork make it tough. But skipping these tasks leads to serious effects like financial loss, patient risks, and bad reputations. Using AI and workflow automation can help make the process easier and improve safety checks. Healthcare leaders should recognize the need for compliance and make good use of tools and support to complete SAFER Guide assessments on time and correctly.
Frequently Asked Questions
What are SAFER Guides?
SAFER Guides are self-assessment tools designed for healthcare organizations to evaluate their electronic health record (EHR) safety practices, identify potential risks, and mitigate those risks, thereby optimizing the safe use of EHRs.
Who can use the SAFER Guides?
The SAFER Guides are intended for eligible hospitals, critical access hospitals (CAHs), and MIPS eligible clinicians participating in the Medicare Promoting Interoperability Program.
What is the purpose of the SAFER Guides?
The purpose of the SAFER Guides is to help organizations reduce EHR-related patient safety risks and foster a culture of safety within healthcare settings.
What does completing a SAFER Guide self-assessment require?
Eligible clinicians under MIPS must report ‘yes’ or ‘no’ on completing an annual self-assessment using the High Priority Practices SAFER Guide.
When must the SAFER Guide self-assessment be completed?
The self-assessment for MIPS eligible clinicians must be completed by December 31 of the performance year.
What happens if the SAFER Guides measure submission is left blank?
Leaving the SAFER Guides measure submission blank will result in a score of 0.
How many SAFER Guides must hospitals complete for attestation?
Eligible hospitals and CAHs are required to attest ‘yes’ or ‘no’ to completing an annual self-assessment using all nine SAFER Guides.
Where can assistance be sought for SAFER Guides?
Assistance can be sought from the Center for Clinical Standards and Quality help desk or the Quality Payment Program Service Center.
What should hospitals do if they do not complete the SAFER Guides assessment?
If hospitals do not complete the assessment, they must report ‘no,’ which signifies they have not met the annual self-assessment requirement.
What is found in the additional resources section related to SAFER Guides?
The additional resources section includes documents like the 2023 MIPS Specification Sheet and the MIPS SAFER Guides Fact Sheet.
