* Healthcare organization should also consider using their Serious Safety Event reporting system, or any alternate or complementary reporting systems used to track patient safety outcomes. 
* When possible, healthcare organizations should consider integrating patient complaints, the narrative portions of patient satisfaction surveys or other mechanisms that patients and families use to communicate concerns about patient safety events. 
o Innovations such as MedStar Health's "We Want to Know" platform specifically designed to prompt complaints and suggestion from users of care, show promising results: Patients in the MedStar system are reporting patient safety events or aspects of events that hospital staff have failed to report \cite{programa}.

 Metrics

Healthcare Organizations should consider using the metrics deployed by CMS to measure the uptake and impact of PFE.
In the acute care (hospital) sector, the CMS Partnership for Patients metrics are:
1. Hospital has a planning checklist that is discussed with every patient who has a scheduled admission, [Level: Direct Care].
a. You'll meet this metric if the hospital uses one of these planning resources:
i. Agency for Healthcare Research and Quality (AHRQ) IDEAL Discharge Planning Overview, Process, and Checklist:   https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.pdf.
ii. Louise H. Batz Patient Safety Foundation, Batz Guide:  http://www.louisebatz.org/patients/the-batz-guide/download-batz-guide/.
iii. What you need to know before and after surgery (World Health Organization): http://www.who.int/surgery/publications/patients_communication_tool.pdf?ua=1.
2. Hospital conducts shift change huddles for staff and does bedside reporting with patients and family members in all feasible cases [Level: Direct Care].
a. You'll meet this metric if the hospital uses any of these tools:
i. Nurse Bedside Shift Report, AHRQ Guide to Patient and Family Engagement in Hospital Quality and Safety: https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy3/index.html.
ii. ISHAPED Patient-Centered Approach to Nurse Shift Change Bedside Report from the Institute for Healthcare Improvement: http://www.ihi.org/resources/Pages/Tools/ISHAPEDPatientCenteredNurseShiftChangeBedsideReport.aspx.
iii. The Family-Centered Rounds Toolkit from the University of Wisconsin--Madison School of Medicine and Public Health; American Family Children's Hospital; and AHRQ: http://www.hipxchange.org/FamilyRounds.
3. Hospital has a designated individual (or individuals) with leadership responsibility and accountability for PFE, (i.e. open chart policy, PFE trainings, establishment and dissemination of PFE goals) [Level: Organizational Design & Governance].
a. You'll meet this metric if the hospital uses one these resources to develop a PFE liaison:
i. Staff liaison to patient and family advisory councils and other collaborative endeavors (Institute for Patient- and Family-Centered Care): http://www.ipfcc.org/resources/Staff_Liaison.pdf.
ii. Working with patients and families as advisors: AHRQ Implementation Handbook: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf.
4. Hospital has an active Patient and Family Advisory Council (PFAC) or at least one patient who serves on a patient safety or quality improvement committee or team. [Level: Organizational Design & Governance].
a. You'll meet this metric if the hospital uses any of the following guides to develop a PFAC:
i. Healthcare Patient Partnership Institute guide to establishing Patient and Family Partnership Councils for Quality & Safety (PFACQS): http://h2pi.org/pfe-toolkit.html
ii. AHRQ guide to developing Patient & Family Advisory Councils: https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy1/index.html
iii. Patient Engagement in Redesigning Care from the University of Wisconsin Health Innovation Program: http://hipxchange.org/PatientEngagement
iv. BJC HealthCare: Patient and Family Advisory Council Getting Started Tool Kit: http://c.ymcdn.com/sites/www.theberylinstitute.org/resource/resmgr/webinar_pdf/pfac_toolkit_shared_version.pdf 
2. Hospital has at least one or more patients who serve on a Governing and/or Leadership Board and serves as a patient representative [Level: Organizational Design & Governance].
a. You'll meet this metric if the hospital uses any of the following guides:
i. Governance Leadership "Boards on Board" How-to Guide from the Institute for Healthcare Improvement: http://www.ihi.org/resources/Pages/Tools/HowtoGuideGovernanceLeadership.aspx
ii. Guidelines for Using Patient Stories with Boards of Directors from the Institute for Healthcare Improvement: http://www.ihi.org/resources/Pages/Tools/GuidelinesforUsingPatientStorieswithBoardsofDirectors.aspx
In the ambulatory care sector, the CMS Transforming Clinical Practice Initiative metrics are:
1. Support for Patient and Family Voices [Level: Organizational Design & Governance]: Are there policies, procedures, and actions taken to support patient and family participation in governance or operational decision-making of the practice (Patient and Family Advisory Councils (PFAC), Practice Improvement Teams, Board Representatives, etc.)?
a. You'll meet this metric if your clinical practice uses any of the following tools for including the perspective and active voice of the patient and family (Patient Family Advisor) in all aspects of the governance of the practice.
i. Forming a Patient and Family Advisory Council in your practice from American Medical Association, https://www.stepsforward.org/modules/pfac
ii. Forming a Patient and Family Advisory Council: AHRQ Case Study from First Street Family Health Center, https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/partnering-1.pdf
iii. Engaging Patients and Families in Improving Ambulatory Care from Robert Wood Johnson Foundation, https://www.rwjf.org/en/library/research/2013/03/engaging-patients-in-improving-ambulatory-care.html
2. PFE Metric 2: Shared Decision-Making [Level: Direct Care].  Does the practice support shared decision-making by training and ensuring that clinical teams integrate patient-identified goals, preferences, outcomes, and concerns into the treatment plan (e.g. those based on the individual's culture, language, spiritual, social determinants, etc.)?
a. You'll meet this metric if your clinical practice is using Patient Reported Outcomes (PROs) and Patient Reported Outcomes Measures (PROMS) or a shared decision-making tool like the ones listed here:
i. Overview on implementation of PROs and PROMs:  https://catalyst.nejm.org/implementing-proms-patient-reported-outcome-measures/ and  https://catalyst.nejm.org/shared-decision-making/
ii. National Institutes of Health inventory of PROMs: http://www.healthmeasures.net/explore-measurement-systems/promis
iii. SHARE informed decision-making tools from AHRQ, https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html.
iv. Choosing Wisely tools from American Board of Internal Medicine and Consumer Reports, http://consumerhealthchoices.org/wp-content/uploads/2013/06/CWPosterGeneralSmall.pdf
v. Ask Me 3 tools from National Patient Safety Foundation, http://www.npsf.org/?page=askme3.
3. PFE Metric 3: Patient Activation [Level: Direct Care].  Does the practice utilize a tool to assess and measure patient activation?
a. You'll meet this metric if your clinical practice is using Patient Activation Measures or other assessments of patient readiness to partner like the ones listed here:
i. Patient Activation Measures (PAM))(proprietary), http://www.insigniahealth.com/products/pam-survey
ii. Stanford Chronic Disease Self-Efficacy Scales, http://patienteducation.stanford.edu/research/secd32.html tool to assess and measure patient activation AHRQ Teach-Back Tool, https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/teach-back.html
4. PFE Metric 4: Active e-Tool [Level: Direct Care]. Does the practice use an e-tool (patient portal or other e-connectivity technology) that is accessible to both patients and clinicians and that shares information such as test results, medication list, vitals, and other information and patient record data?
a. You'll meet this metric if the practice uses (and makes available to patients) an e-tool such as OpenNotes that allows patients to access their medical record and have an easy, direct way to communicate with providers.  Examples include:
i. OpenNotes, https://www.opennotes.org/.
ii. OpenNotes Case Study from AHRQ, https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/opennotes-1.pdf
iii. HIMSS patient engagement toolkit, http://www.himss.org/library/patient-engagement-toolkit.
iv. Patient Engagement Playbook from the office of the National Coordinator for h Health Information Technology, https://www.healthit.gov/playbook/pe/
v. AHRQ Health Information toolkit, https://healthit.ahrq.gov/health-it-tools-and-resources
5. PFE Metric 5: Health Literacy Survey [Level: Direct Care].  Is a health literacy patient survey being used by the practice (e.g., CAHPS Health Literacy Item Set)?
a. You'll meet this metric if your practice use tools like the ones listed below to systematically address health literacy through universal precautions and assessing how well patients understand information provided to help them manage their health. 
i. AHRQ Health Literacy Universal Precautions toolkit, https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.html
ii. Health Literacy Toolshed, http://healthliteracy.bu.edu/all
iii. AHRQ Health Literacy Measurement toolkit, https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html 
iv. Industry Collaboration Effort Better Communication, Better Healthcare toolkit, http://www.iceforhealth.org/library/documents/ICE_C&L_Provider_Toolkit_7.10.pdf
6. PFE Metric 6: Medication Management [Level: Direct Care].  Does the clinical team work with the patient and family to support their patient/caregiver management of medications?
a. You'll meet this metric if there is a systematic, standard method in place to evaluate and support patients and their caregivers in medication self-management. There are many toolkits including these:
i. AHRQ medication management toolkit, https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/medmanage.html.
ii. American Medical Association module on medication management, https://www.stepsforward.org/modules/medication-adherence.
iii. Health Services Advisory Group Medication Management toolkit, https://www.hsag.com/en/medicare-providers/care-coordination/medication-management/.
iv. Canadian Patient Safety Institute and Institute for Safe Medication Practices Canada, 5 Questions to Ask About Your Medications, http://www.patientsafetyinstitute.ca/en/toolsResources/5-Questions-to-Ask-about-your-Medications/Pages/default.aspx.
Additional Resources
1. PFE resources are easily accessed yet need to be encouraged along the continuum of care.
a. You can encourage PFE by providing updated resources and conversing with patients and family members about how they may utilize the information. The following resources have been identified as useful by patients and/or their family members.
i. An Empowered Patient ®, www.EmpoweredPatientCoalition.org
ii. Patient Aider, https://www.youtube.com/watch?v=EajJPfyBY-0, http://patientsafetymovement.org/news/patient-safety-movement-foundation-launches-free-patientaider-app/
iii. EngagedPatients.org, Engaged Patients is a national campaign under the guidance of the Empowered Patient Coalition nonprofit with the vision that all patients and their loved ones have free access to the tools and the resources they need to be fully informed and participating members of their health care teams., http://engagedpatients.org/wp-content/uploads/2014/06/epc_patient_journal.pdf
iv. Minnesota Alliance for Patient Safety, You: Your Own Best Medicine, http://ownbestmedicine.mn
v. AHRQ Be Prepared to Be Engaged tool, https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/beprepared.html
vi. AHRQ Teach-Back Tool, https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/teach-back.html
vii. AHRQ Question Builder tool for patients, https://www.ahrq.gov/patients-consumers/question-builder.html
viii. Motivational Interviewing tools, http://www.practiceadvisor.org/Modules/improving-clinical-care/motivational-interviewing/login?ReturnUrl=/Modules/improving-clinical-care/motivational-interviewing [Note:  Access requires registration, but it is grant supported so there is no cost to users].
2. Education: Everyone from youth to the most experienced clinician has an opportunity to improve healthcare safety through increased PFE.
a. You can contribute by educating others within your area of influence.
i. Educating future leaders in patient safety, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181734/.
ii. The WHO Multi-Professional Patient Safety Curriculum Guide, http://www.who.int/patientsafety/education/curriculum/Curriculum_Tools/en/.
iii. Academy for Emerging Leaders in Patient Safety, http://thetellurideexperience.org.
iv. Canadian Patient Safety Institute, Patient Safety Education Program Core Curriculum, http://www.patientsafetyinstitute.ca/en/education/PatientSafetyEducationProgram/PatientSafetyEducationCurriculum/Pages/default.aspx.
Additional Resources
1. PFE resources are easily accessed yet need to be encouraged along the continuum of care.
a. You can encourage PFE by providing updated resources and conversing with patients and family members about how they may utilize the information. The following resources have been identified as useful by patients and/or their family members.
i. An Empowered Patient ®, www.EmpoweredPatientCoalition.org
ii. Patient Aider, http://patientsafetymovement.org/challenges-solutions/resources/
iii. EngagedPatients.org, Engaged Patients is a national campaign under the guidance of the Empowered Patient Coalition nonprofit with the vision that all patients and their loved ones have free access to the tools and the resources they need to be fully informed and participating members of their health care teams., http://engagedpatients.org/wp-content/uploads/2014/06/epc_patient_journal.pdf
iv. Minnesota Alliance for Patient Safety, You: Your Own Best Medicine, http://ownbestmedicine.mn
v. AHRQ Be Prepared to Be Engaged tool, https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/beprepared.html
vi. AHRQ Teach-Back Tool, https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/teach-back.html
vii. AHRQ Question Builder tool for patients, https://www.ahrq.gov/patients-consumers/question-builder.html
viii. Motivational Interviewing tools, http://www.practiceadvisor.org/Modules/improving-clinical-care/motivational-interviewing/login?ReturnUrl=/Modules/improving-clinical-care/motivational-interviewing [Note:  Access requires registration, but it is grant supported so there is no cost to users].
2. Education: Everyone from youth to the most experienced clinician has an opportunity to improve healthcare safety through increased PFE.
a. You can contribute by educating others within your area of influence.
i. Educating future leaders in patient safety, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181734/.
ii. The WHO Multi-Professional Patient Safety Curriculum Guide, http://www.who.int/patientsafety/education/curriculum/Curriculum_Tools/en/.
iii. Academy for Emerging Leaders in Patient Safety, http://thetellurideexperience.org.