The Safe Healthcare System Patients Deserve
A National Call to Action for Federal Leadership on Patient Safety
The Safe Healthcare System Patients Deserve: A National Call to Action for Federal Leadership on Patient Safety
The Honorable Robert F. Kennedy, Jr.
Secretary, U.S. Department of Health and Human Services
The Honorable Mehmet Oz, MD
Administrator, Centers for Medicare & Medicaid Services
Dear Secretary Kennedy and Administrator Oz:
We, the undersigned patients, family caregivers, dedicated healthcare workers, improvement experts, and patient safety advocates, urge you to lead a renewed national commitment to building the safe healthcare system every American deserves. We ask you to make patient safety a foundational expectation of healthcare delivery and to use the full range of HHS and CMS policy levers to make this expectation a reality.
Safe care must be more than a shared aspiration. It must be a foundational expectation, supported by the leadership, systems, and resources needed to deliver it reliably.
More than 25 years after To Err Is Human launched a national call to action to improve patient safety, preventable harm remains a profound challenge. One in four hospitalized patients experiences an adverse event, and missed, wrong, or delayed diagnoses contribute to death or permanent disability of up to 1.2 million Americans annually.
We appreciate federal leadership to date. We see the important advances that have been made in understanding why patients are harmed and developing best practices to avoid harm. We now have an extraordinary opportunity to build on that progress, harness new technologies, learn systematically from patients’ experiences to improve, and align federal policies to provide safer care to every patient in every healthcare setting.
We Cannot Achieve Safer Care Simply by Measuring Harm after it Occurs. An Extraordinary Opportunity is Now at Hand to Build a System Designed to Proactively Prevent it. In its August 2026 report, Targeting Improvements in Patient Safety Through Alternative Payment Models, the HHS Physician-Focused Payment Model Technical Advisory Committee (PTAC) calls for a more ambitious, preventive approach to patient safety—one that strengthens organizational capability, brings patients' experiences into the measurement of safety, and rewards investments in improvement. This vision can be translated into action through these proposed actions and your commitment to achieving optimal patient outcomes.
First, Make the Capability to Deliver Safe Care a Condition of Participation in Medicare.
CMS has already taken important steps through its Patient Safety Structural Measure (PSSM) and Age-Friendly Hospital Measure (AFHM), which establish expectations for the organizational leadership, systems, and practices essential to safe care. Now we urge you to take the next step: elevate the PSSM and AFHM into Medicare Conditions of Participation. Every participating hospital should be accountable for demonstrating the leadership, workforce culture, infrastructure, and meaningful patient and family engagement necessary to prevent harm and continuously improve. These capabilities are not optional attributes of excellent care. They are prerequisites for safe care.
Second, Make Patients and Families Indispensable Partners in Identifying and Preventing Harm.
The healthcare system cannot prevent risks it does not recognize, and patients and families often see what the system misses. Dismissed concerns, delayed diagnoses, communication failures, and dangerous gaps in care frequently escape traditional safety surveillance. We call on CMS to modernize standardized patient surveys and reporting systems to capture patient-reported experiences and outcomes as essential intelligence about whether health care is safe. Use accessible, technology-enabled approaches to make reporting easier and integrate patient-generated feedback with clinical and other safety data to inform timely action and continuous improvement.
Third, Make Preventing Harm a Better Investment than Tolerating It.
Healthcare organizations need both accountability for safety and incentives to invest in preventing harm. As PTAC recognizes, approaches that focus primarily on penalizing poor outcomes can discourage transparency without providing the support needed to address underlying risks.
We call on CMS to make patient safety central to existing and future Alternative Payment Models and to test innovative approaches that reward measurable improvement. PFPS US’s PIVOT Earn-Back Value Model, discussed in PTAC's report, illustrates how payment incentives could reward investments in patient safety and demonstrated improvement in performance. The objective is to make preventing harm the better clinical, organizational, and financial decision.
Fourth, Harness the Power of The Technology to Improve Safety
CMS should use its policy levers to accelerate the responsible use of Artificial Intelligence, interoperable data, and other technologies to connect patient reported experiences and outcomes with clinical and other safety information, identify emerging risks, and support intervention before patients are harmed. This integrated, continuously learning approach can help make the health care system itself safer, not merely its individual technologies. CMS should use its policy authorities and Quality Improvement Organization program to assist in this transformation.
What we need now is the National Commitment to put these Bold, but Highly Achievable Strategies to Work. Patient Safety should not depend on luck, geography, or the priorities of individual healthcare organizations. As PTAC's recent report underscores, federal policymakers already possess powerful tools to accelerate progress.
The patient safety community stands ready to work with you. Together, we can build a healthcare system in which avoiding preventable harm is not an exceptional achievement, but the standard every patient can expect, in every healthcare setting.
Patients Deserve Nothing Less.
Respectfully,
Patients for Patient Safety US and undersigned individuals