IA_PSPA_4Patient Safety and Practice Assessment

Administration of the AHRQ Survey of Patient Safety Culture

2026 MIPS Improvement Activities

At a glance
Activity ID
IA_PSPA_4
Subcategory
Patient Safety and Practice Assessment
Category
Improvement Activities

Objective

Create the opportunity to i) Raise staff awareness about patient safety; ii) Elucidate and assess the current status of patient safety culture; iii) Identify strengths and areas for patient safety culture improvement; iv) Evaluate trends in patient safety culture change over time; and v) Evaluate the cultural impact of patient safety initiatives and interventions (from https://www.ahrq.gov/sops/about/faq.html#Q1).

Activity description

Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patientsafety/patientsafetyculture/index.html). Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

Suggested documentation

Evidence of administration of the Agency for Healthcare Research and Quality (AHRQ) survey of Patient Safety Culture and submission of data to the comparative database. Include the following element:

1) Survey results data submission – Survey results from the AHRQ Survey of Patient Safety Culture, including proof of administration and submission.

Improvement Activity details reference the CMS Quality Payment Program and change each performance year. Confirm requirements against the official CMS pages before attesting.