As hospitals continue to face quality and cost pressures in 2025, hospital leaders are prioritizing patient safety objectives to enhance care quality and reduce risks. From readmissions management and CMS Star Ratings to addressing high-cost diagnoses and new structural measures, healthcare quality leaders are striving for a comprehensive patient safety strategy to drive improvements.

That’s what five hospital leaders in quality, compliance, and patient safety shared in recent interviews with American Data Network. While challenges remain, these professionals are moving forward with tools and strategies for quality improvement and patient safety, leveraging multidisciplinary collaboration to achieve results in 2025 and beyond.

Patient Safety Strategy #1: Reducing Readmissions Through Proactive Care

Many quality, safety, and compliance leaders continue to focus on reducing hospital readmissions as a core patient safety objective.

“For us, readmissions is one of the big things we’re focusing on, as well as patient satisfaction,” shares Cara Cruz, BA, RN, CIC, CPHQ, Director of Risk and Quality, Patient Safety Officer, and Infection Control Officer at Carson Valley Health. Cruz calls readmission prevention “a real challenge” requiring a multifaceted patient safety strategy.

At Carson Valley, a comprehensive discharge planning process ensures patients have their medications and post-discharge care within two business days. Monthly focus groups analyze readmitted patients, using risk stratification models to guide outreach:

• Care managers engage low-risk patients.
• Provider clinics focus on high-risk patients based on diagnosis criteria.

This approach has been “hugely, widely successful,” Cruz says.

However, data access remains a barrier. While internal readmissions are trackable, external readmissions—those occurring at unaffiliated hospitals—are often invisible in the system.

At Unity Health in Arkansas, Timothy Copeland, MT (ASCP), MHA, Director of Quality/Risk Management, emphasizes that optimizing discharge efficiency and reducing readmissions are key priorities for their patient safety strategy in 2025.

Patient Safety Strategy #2: Strengthening Quality and Safety Measures

Facilities are also making a push to meet CMS’ expanding group of structural measures surrounding patient safety. That is going to be a major focus at San Luis Valley Health Regional Medical Center in Alamosa, Colorado, says Margaret White, CPHQ, Director of Quality and Safety at the facility.

White notes new structural measures that CMS finalized in the 2025 Hospital Inpatient Prospective Payment System (IPPS) final rule that begin during the 2025 reporting year, including the Patient Safety Structural Measure (PSSM) and the Age Friendly Structural Measure. Both of the new measures are linked to 2027 payment determinations.

“CMS is finalizing several new hospital quality initiatives, including digital measures for patient harm events, expansion of healthcare-associated infection measures to oncology wards, and structural measures to support safety and age-friendly care,” the agency said. “The new attestation-based structural measures assess whether hospitals demonstrate a structure, culture, and leadership commitment that prioritizes and implements best practices for patient safety and age-friendly care.”

Each of the new measures has five attestation domains. PSSM domains include:

• Domain 1: Leadership Commitment to Eliminating Preventable Harm
• Domain 2: Strategic Planning and Organizational Policy
• Domain 3: Culture of Safety and Learning Health System
• Domain 4: Accountability and Transparency
• Domain 5: Patient and Family Engagement

The Age Friendly Hospital Measure attestation domains cover:

• Domain 1: Eliciting Patient Healthcare Goals
• Domain 2: Responsible Medication Management
• Domain 3: Frailty Screening and Intervention
• Domain 4: Social Vulnerability
• Domain 5: Age-Friendly Care Leadership

In the 2025 IPPS rule, CMS also said it would modify two current measures, with one revision affecting facilities in 2025: The agency is changing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure beginning in the 2025 reporting year (payment determinations in 2027). The revisions to the HCAHPS Survey add three new survey sub-measures, remove one existing survey sub-measure and revise one existing survey sub-measure, according to CMS.

According to White of San Luis Valley Health, while a lot of national groups are providing education about the new measures, finding an organization or third-party that can help hospitals navigate both of the new measures can be a challenge. “I haven’t found a group that’s focusing on both,” White says.

What’s more, the measures – and the work they entail – can further pinch scarce hospital resources. “It’s hard to find the funds to meet the measures,” White adds.

At Cheyenne Regional Medical Center, hospital leaders are taking a proactive approach to navigating the new measures. “We’re meeting monthly to go over every measure,” says Brianna Best Lima, BA, MA, CPHQ, Manager, Data Management at Cheyenne Regional. That focus aligns with Cheyenne’s “ramping up efforts around value-based care and patient safety,” Lima says.

For hospitals looking to assess and improve their patient safety culture, resources such as the Hospital Survey on Patient Safety Culture provide valuable insights into safety perceptions, reporting behaviors, and areas needing attention.

Patient Safety Strategy #3: Achieving Higher CMS Star Ratings

Publicly reported CMS Star Ratings continue to influence hospital performance initiatives, shaping strategic priorities for 2025 and beyond.

Hospitals with a well-established culture of safety in healthcare tend to excel in CMS safety metrics, as they proactively address risks, implement best practices, and engage staff in continuous quality improvement.

“Our focus is related to publicly reported data and patient experience feedback that doesn’t always make it into reports,” says Copeland of Unity Health.

The CMS Star Ratings system evaluates hospitals across five key domains:

• Mortality
• Safety of care
• Readmission rates
• Patient experience
• Timely and effective care

According to CMS data, most hospitals are in the three-star (17.8%) and four-star (16.4%) range, while fewer than 10% achieve five-star status.

For Carson Valley Health, improving their Star Rating is a top priority. “A primary goal in 2025 will be to move into the five-star category,” Cruz.

By refining quality improvement strategies and leveraging proactive patient engagement initiatives, hospitals can improve CMS ratings while also advancing their overall patient safety strategy.

Patient Safety Strategy #4: Managing High-Cost Patient Populations to Improve Outcomes and Reduce Costs

Cheyenne Regional is also working to address the “high-dollar, high-cost patients,” Lima says. That includes focusing on high-cost diagnostic groups, such as those with heart failure and those undergoing chemotherapy.

Hospitals that prioritize high-cost patient populations can see multiple benefits, both in cost containment and patient outcomes. These patients often require frequent hospital visits, specialized treatments, and complex care coordination, which can strain hospital resources if not managed effectively. By identifying and addressing these groups proactively, hospitals can reduce avoidable hospitalizations, optimize resource allocation, and improve overall efficiency.

At Northwell Health in New York, the 21-hospital system has taken steps to stem costs by proactively addressing the “mental health crisis” that has been on the uptick since the COVID-19 pandemic, says Peter Silver, M.D., MBA, Senior Vice President and Chief Quality Officer with Northwell Health. “Hospitals are under increasing financial pressure,” Silver says. Northwell embarked on a multiyear initiative to reduce unnecessary hospitalizations and attendant costs by screening all ambulatory patients for depression.

To date, the health system has successfully screened some 2 million patients, Silver says. Northwell also places a heavy emphasis on disease management for highly prevalent conditions like hypertension and steers patients toward preventive services, such as colonography and mammography, that can identify diseases early and reduce downstream spending.

Focusing on high-cost patient management aligns with value-based care initiatives, which emphasize preventing complications and unnecessary admissions rather than just treating acute episodes. This approach can also enhance patient experience and satisfaction, as better coordination and targeted interventions often lead to fewer disruptions in care and improved quality of life.

By refining strategies for high-cost, high-risk patients, hospitals can balance financial sustainability with improved patient outcomes, reinforcing their overall patient safety strategy while maintaining compliance with performance-based reimbursement models.

Conclusion

In 2025, hospital leaders are embracing a dynamic, multifaceted patient safety strategy to navigate the evolving challenges of healthcare quality. From reducing readmissions and improving CMS Star Ratings to adopting new quality measures and managing high-cost patient populations, hospitals are refining their approaches to drive better outcomes and financial sustainability.

Yet, as Silver at Northwell Health emphasizes, there is no singular focus when it comes to quality and safety efforts. Instead, organizations must continuously adapt, minimize errors, and—most importantly—learn from them. By leveraging proactive strategies, data-driven insights, and collaborative leadership, hospitals can build a stronger, safer healthcare system that prioritizes both patient well-being and long-term success.

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A culture of safety in healthcare is more than just a strategic priority on a roadmap; it’s a foundational element of high-quality patient care. When healthcare organizations prioritize safety, they see improvements not only in clinical outcomes but also in patient satisfaction, operational efficiency, and staff morale.

Yet, creating a culture of safety in healthcare requires more than policies and protocols—it demands a leadership-driven commitment to fostering an environment where safety is at the forefront of every decision, action, and communication.

Culture of Safety in Healthcare: Impact on Clinical Indicators and Reducing Adverse Events

One of the most significant benefits of a culture of safety in healthcare is its ability to reduce adverse events. By creating an environment that encourages transparent communication, continuous learning, and a proactive approach to risk management, healthcare organizations can achieve substantial improvements in clinical outcomes.

1. Reduction in Surgical Site Infections (SSIs)

A robust safety culture healthcare can significantly lower the incidence of SSIs. One recent study assessing the surgical outcomes at a group of community hospitals in Minnesota found a significant link between aspects of safety culture and decreased rates of surgical site infections (SSI) following colon surgery. In this study, researchers tracked the Hospital Survey on Patient Safety Culture and National Healthcare Safety Network definitions and colon SSI rates. Ultimately, nine out of 12 dimensions of a patient safety culture “were significantly associated with lower colon SSI rates,” according to the study. (Fan et al., J Am Coll Surg, Feb. 2016)

Key safety culture dimensions linked to lower SSIs include:

• Teamwork across and within units,
• Organizational Learning,
• Communication about Error,
• Management Support for Patient Safety, and
• Supervisor/Manager Expectations and Actions Promoting Safety, among others.

2. Reduction in Patient Falls

Patient falls are a common adverse event in healthcare settings, leading to increased morbidity, longer hospital stays, and higher costs. However, facilities that cultivate a culture of safety in healthcare see substantial reductions in fall rates. According to a 2023 study in the Journal of Clinical Nursing, units with a strong safety climate and collaborative teamwork—particularly between nurses, physicians, and pharmacists—reported fewer patient falls. (Alanzi et al., J Clin Nurse, Oct. 2023)

3. Decrease in Hospital-Acquired Infections (HAIs)

Additional research has added to the body of evidence tying a positive culture of safety to health outcomes:

• A lower chance of hospital-acquired infections, including catheter-associated urinary tract infections and central line-associated blood stream infections;
• A decrease in urinary tract infections and ulcers among the elderly; and
• Higher quality ratings assessing a patient’s stay.

Using Surveys to Strengthen a Culture of Safety in Healthcare

An effective way to measure and enhance a culture of safety in healthcare is through a Survey on Patient Safety Culture (SOPS). These surveys provide valuable insights into staff perceptions of safety practices, communication openness, and leadership support. Conducting regular SOPS assessments allows healthcare organizations to:

• Identify strengths and areas for improvement in safety culture.
• Measure the impact of safety initiatives on staff perceptions.
• Benchmark performance against national standards for patient safety.

American Data Network offers an SOPS Service designed to help healthcare organizations administer, analyze, and act on the results of these surveys. By leveraging ADN’s expertise, hospitals can gain comprehensive analytics reports that drive targeted safety interventions and foster a culture of continuous improvement.

Enhancing Patient Experience with a Culture of Safety in Healthcare

A high-quality culture of safety in healthcare not only prevents adverse events but also enhances the overall patient experience. Patients who feel safe and secure are more likely to report positive experiences, leading to higher satisfaction scores and improved hospital reputations.

A study published in the Journal of Patient Safety explored the relationship between patient safety culture and patient experiences. Researchers found a significant positive correlation between high staff safety culture scores (using the Hospital SOPS tool) and high patient satisfaction scores (using the CAHPS Hospital Survey).

• Facilities with a strong culture of safety received better ratings for communication, staff responsiveness, and overall patient care experience.
• Twelve out of fifteen safety culture dimensions were positively linked to improved patient satisfaction scores, demonstrating that safety culture impacts every aspect of patient interactions.

These findings underscore the strategic advantage of prioritizing a culture of safety healthcare not only to improve clinical outcomes but also to foster positive patient relationships and enhance overall experiences.

Leadership’s Role in Building a Culture of Safety in Healthcare

Successful implementation of a culture of safety in healthcare hinges on leadership’s commitment to safety as a core organizational value. Leaders play a pivotal role by:

• Setting Clear Expectations: Establishing safety as a non-negotiable priority for all staff levels.
• Modeling Safety-First Behavior: Demonstrating accountability and transparency when addressing safety concerns.
• Encouraging Open Communication: Creating a non-punitive environment where staff feel safe to report errors and near-misses without fear of retribution.
• Investing in Continuous Learning: Supporting ongoing education and training initiatives to keep staff updated on best practices and emerging safety trends.

An annual perspective by the Patient Safety Network (PSNet) emphasized that leadership’s support and involvement are crucial for embedding a healthcare culture of safety across all organizational layers. (PSNet Annual Perspective, March 2024)

Conclusion: Why a Culture of Safety in Healthcare is a Strategic Imperative

A culture of safety in healthcare is not just about compliance or reducing adverse events; it is about creating an environment where patients feel secure, staff feel supported, and clinical outcomes are optimized. Healthcare leaders who prioritize safety culture healthcare:

• Build Trust: Patients are more likely to trust and recommend facilities known for their safety commitment.
• Boost Financial Performance: By reducing adverse events and hospital-acquired infections, facilities save on costs associated with readmissions, extended stays, and legal claims.
• Enhance Organizational Reputation: A strong safety culture reinforces a facility’s reputation as a leader in patient-centered care.

As healthcare organizations navigate an increasingly complex landscape, investing in a culture of safety in healthcare is a strategic imperative for sustainable success. Facilities that champion safety as a core value will not only improve patient outcomes but also achieve long-term operational excellence.

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Hospital leaders, compliance directors, and institutional safety advocates now have a powerful patient safety dashboard at their fingertips. The innovative National Healthcare Safety Dashboard serves as a robust hospital patient safety dashboard designed to assess, analyze, and improve hospital safety data. Developed through the collaboration of federal agencies and private partners, this dashboard will help hospitals benchmark their performance against the current state of patient and workforce safety.

Background on the Patient Safety Dashboard

Launched in December 2024, the National Healthcare Safety Dashboard is a comprehensive tool that focuses on some of the most consequential hospital safety data metrics impacting patient safety nationwide. By aggregating data from four key sources, this hospital patient safety dashboard provides granular details on specific safety events, clinical indicators, and patient survey responses across four broad categories.

Three of the four dashboard categories are sourced from the Agency for Healthcare Research and Quality (AHRQ), and the other one comes from the Centers for Medicare and Medicaid Services (CMS). The four data sources include:

• Hospital Patient Safety Indicators (AHRQ).
• Hospital Medicare Adverse Events (AHRQ).
• Hospital Reporting Program Safety Measures (CMS).
• Surveys on Patient Safety Culture (SOPS) Hospital Survey (AHRQ).

While the patient safety dashboard currently focuses on hospital-based metrics, AHRQ officials have indicated plans to expand its scope to ambulatory settings and nursing homes. This hospital patient safety dashboard is a creation of the National Action Alliance for Patient and Workforce Safety (NAA), a collective of federal agencies and private partners formed within AHRQ in 2023 that seeks to meet the stated goals of AHRQ’s National Advisory Council to reduce patient and workforce harm by 50% by 2026.

The NAA supports five primary tactics to meet national goals in reducing patient safety adverse events and “help all healthcare systems strengthen their patient and workforce safety outcomes.” The five aims include:

• Conducting self-safety assessments to assess a baseline measure of performance.
• Empowering patient feedback to steer strategic aims (e.g., allowing patients’ safety concerns to flow into facilities’ event reporting systems).
• Redesigning the workplace and team units to support workforce safety.
• Strengthening the training of all workforce members in safety competencies.
• Promoting research, learning, and process-sharing (e.g., harm reduction strategies) across networks.

The hospital safety data aggregated by the NAA is essential for tracking progress and measuring improvements in Adverse Events in Hospitals and other key indicators. “The National Healthcare Safety Dashboard is one approach to tracking our progress on patient and workforce safety nationally using measures prioritized by national programs,” the NAA states.

A Closer Look at the Data

Each of the four key data sources that comprise this patient safety dashboard contains sub-elements that delve into the latest national measures – providing a benchmark that facilities can use as they start on, or continue, their journey to enhanced harm reduction. In all cases, the charts and tables present the latest available federal data. The following section provides a closer look at the primary data categories and their sub-elements.

Hospital Patient Safety Indicators

This category includes more than a dozen condition- or event-related safety indicators, as follows:

• Death rate in low-mortality diagnosis related groups (DRGs) (PSI-02)
• Pressure ulcer rate (PSI-03)
• Iatrogenic pneumothorax rate (PSI-06)
• Central venous catheter-related bloodstream infection rate (PSI-07)
• In-hospital fall with hip fracture rate (PSI-08)
• Postoperative hemorrhage or hematoma rate (PSI-09)
• Postoperative acute kidney injury requiring dialysis rate (PSI-10)
• Postoperative respiratory failure rate (PSI-11)
• Perioperative pulmonary embolism or deep vein thrombosis rate (PSI-12)
• Postoperative sepsis rate (PSI-13)
• Postoperative wound dehiscence rate (PSI-14)
• Abdominopelvic accidental puncture or laceration rate (PSI-15)
• Birth trauma rate – injury to neonate (PSI-17)

If you navigate through the data sets, you’ll find overall risk stratification levels for the various safety indicators. For instance, the post-operative sepsis rate shows a rolling national risk level from the period between 2016 and 2021, during which time facilities saw a significant reduction in post-op sepsis rates, decreasing from five cases per 1,000 discharges to about three-and-a-half cases per 1,000. Users can also mine the data further, stratifying the data based on patient variables (e.g., age group, expected payer, patient sex).

Facilities like ADN’s clients using the Clinical Benchmarking System have access to this type of benchmarking data already.

Hospital Medicare Adverse Events

One of the briefer data sets on the Safety Dashboard, the adverse events page shows two levels of stratification: patients with at least one adverse event during hospitalization; and total adverse events per 1,000 discharges. In both cases, the number of events showed favorable progress between 2021 and 2022, the latest year of available data. The cumulative number of adverse events per 1,000 discharges, for instance, fell from about 83.6 to 71.1.

Adverse events were identified using AHRQ’s Quality and Safety Review System (QSRS) to abstract information from hospital records. Measures include composite adverse event rates.

CMS Hospital Reporting Program Safety Measures

The safety performance data segment of the dashboard contains seven sub-elements, from hospital-associated infections to surgical site infections and complications. This portion of the dashboard contains some of the most recent data available, ending in calendar year 2024. The full list covers:

• Central-line associated bloodstream infections: Intensive care unit plus select wards (HAI-1)
• Catheter-associated urinary tract infections: ICU only (HAI-2)
• Surgical site infection: Colon surgery (HAI-3)
• Surgical site infection: Abdominal hysterectomy (HAI-4)
• Death for surgical inpatient with serious treatable complications (PSI-04)
• Complications for hip/knee replacements (COMP-HIP-KNEE)
• Appropriate care for severe sepsis/septic shock (SEP-1)
  • Check out ADN’s checklists for Severe Sepsis and Septic Shock.

Surveys on Patient Safety Culture (SOPS) Hospital Survey

Based on the SOPS data tool, the dashboard’s survey-based data covers 11 composite measures, and compares survey results year-over-year. The SOPS tool assesses “provider and staff perceptions of patient safety culture.” Within the dashboard, the covered measures include:

• Communication about error.
• Communication openness.
• Handoffs and information exchange.
• Hospital management support for patient safety.
• Organizational learning – continuous improvement.
• Reporting patient safety events.
• Response to error.
• Staffing and workplace.
• Supervisor, manager or clinical leader support for patient safety.
• Teamwork.
• Unit/work area patient safety rating.