Person/Patient and Family Engagement Metrics

There are five patient/person and family engagement (PFE) metrics that are defined and a part of CMS’s Partnership for Patients.

These metrics are explained with examples in the PFE Roadmap and the PFE Addendum (shorter version).

Click any metric to expand.

Metric #1: Planning Checklist for Scheduled Admissions
This metric is about that your hospital, prior to admission, have staff that provides and discusses a planning checklist with every patient that has a scheduled admission, allowing for questions or comments from the patient and family. This checklist could be sent prior to the admission or at the time of arrival at the hospital.

If your hospitals do not have scheduled admissions, the hospital is exempt from this metric.

Examples/Implementation Resources

Metric #1 Learning Event Resources

How to Create Opportunities to Engage with Patients and Families at Admissions and Beyond (7/11/17 video).   Lee Thompson of the American Institutes for Research (AIR), the Person and Family Engagement Contractor (PFEC) for PfP, will discuss the six PFE strategies in the Roadmap and how to apply them to meet each PFE metric. Ms. Thompson will also discuss how to apply the PFE strategies in ways that can help achieve equity in health care quality and safety and address barriers to uniform engagement of patients and families from diverse cultural, ethnic, or socioeconomic backgrounds.


Metric #2: Shift Change Huddles/Bedside Reporting with Patients and Families
This metric is about your hospital conducting shift change huddles and bedside reporting with patients and family members, in all feasible cases. You meet this metric if a minimum of one unit implements this best practice but the ideal is to have all units.

Examples/implementation resources

Memorial Hospital & Health Care Center Resources.  Bedside shift report implementation timeline, patient letter, bedside shift reporting process, CNA shift report process, charge nurse guide, post surgical services nursing survey and post surgical services bedside shift reporting

ISHAPED Patient-Centered Approach to Nurse Shift Change Bedside Report. The “ISHAPED” (I=Introduce, S=Story, H=History, A=Assessment, P=Plan, E=Error Prevention, and D=Dialogue) project focuses on making bedside shift reports more patient- and family-centered. The goal is to always include patients in the ISHAPED nursing shift-to-shift handoff process at the bedside to add an additional layer of safety by enabling the patient to communicate potential safety concerns.

Making the Most of Shift Change Huddles at the Bedside: Tips for Patients and Caregivers.  Including patients and families as extra “eyes and ears” to maintain high quality care means giving them a clear path of communication. A handout shared with the patient upon admission establishes a clear course of action that patients and families can follow.

Baptist Memorial Health Care Corporation Resources. Hand-off communication process,
bedside report scripting and 2012 Kardex HOC form with skin assessment.

Patient and Family Rounding Daily Summary.  Patients and families can use this form to participate in rounds and to organize their observations, questions and goals

Metric #2 Learning Event Resources

Engaging patients with Shift Change Huddles at the Bedside (video).

Master Class 3: Shift Change Huddles at the Bedside (9/23/13).  Click through for recording, slides, and other resources.


Metric #3: Accountable Leader or Program Area
This metric is about having a person or functional area/department, who may have another role/title in the hospital, that is dedicated and proactively responsible for Patient/Person and Family Engagement and regularly monitors activities. This could also be a functional department (i.e. patient experience, patient advocacy, quality improvement).

Examples/implementation resources

Staff Liaison and Patient and Family Engagement.  Staff liaison: Any role that enables consumers to have direct input and influence on the policies, programs, and practices that affect the care and services that individuals and families receive.

Metric #3 Learning Event Resources

Master Class 4: Staff Assigned to PFE.  Click through for recording, slides, and other resources.


Metric #4: Having a Patient and Family Advisory/Engagement Council (PFAC/PFEC) or a Patient/Family Representative on the Quality Improvement team
This metric is about your hospital having an active Patient and Family Engagement Committee (PFEC) or Patient and Family Advisory Committee (PFAC) or at least one former patient that serves on a patient safety or quality improvement committee or team.

Examples/implementation resources

CMS Presentation: How to Create and Sustain a Patient and Family Advisory Council (PFAC) to Improve Patient Safety: Person and Family Engagement (PFE) Metric 4.

Partnership for Patients (PfP) 2.0: How to Create and Sustain a Patient and Family Advisory Council (PFAC) to Improve Patient Safety: Person and Family Engagement (PFE) Metric 4. Trainer’s Guide
Developed by American Institutes for Research® Person and Family Engagement Contractor (PFEC), September 2016.

Forming a Patient and Family Advisory Council.  Eight STEPS to form a Patient and Family Advisory Council (PFAC), answers to frequently asked questions about PFACs and  tools and resources to help you and your team advance patient and family engagement strategies.

Brigham and Women’s Faulkner Hospital Patient and Family Advisory Council (PFAC).

Patient and Family Advisory Council Getting Started Tool Kit.

Health Equity and Patient and Family Engagement (recording 5/10/16).  Click through for recording and presentation on heath equities and PFE.

Metric #4 Learning Event Resources

How to Recruit and Maximize a Representative Patient and Family Advisory Council to Improve Patient Safety (6/13/17).  Click through for recording and presentation.


Metric #5: Patient and Family on Hospital Governing and/or Leadership Board (hospital governance)
This metric is about your hospital having at least one or more patient(s) or family members who serve on a governing and or leadership board AND serves as a patient representative.

For Public District Hospitals, one of the elected board members are involved in a patient and family focused committee or team.

Examples/implementation resources

Guidelines on how to use Patient stories with Board of Directors.

Master Class on Patients on Governing Board.

HIPAA Privacy and Joint Commission Standards – Partnerships with patients and families are not barriers.

Metric # 5 Learning Event Resources


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