Other PFE Frameworks worthy of consideration include:
* Health Information and Management Systems Society, Patient Engagement Framework
* American Hospital Association, Engaging Health Care Users: A Framework for Healthy Individuals and Communities 
* FasterCures Patient Perspective Value Framework
Guided by the Carman framework, in 2013 the United States Centers for Medicaid and Medicare Services (CMS) deployed five PFE metrics in a nationwide effort to reduce ten Hospital Acquired Conditions (HACs) as an integral part of its Partnership for Patients campaign.   The five hospital-based PFE metrics are expanded upon in the Practice Plan of this Actionable Patient Safety Solutions (APSS).  Verified results to date show that hospitals with robust person and family engagement achieved greater reduction in HAC frequency and did so at a faster rate.   Based on these initial results, in 2015, six PFE metrics were deployed by CMS in the ambulatory care sector as part of its Transforming Clinical Practice Initiative.  The six ambulatory care-based metrics are explained in detail in the Practice Plan of this APSS.
Research and evidence continues to accumulate for the impact of PFE for achieving zero harm, prompting CMS to incorporate PFE into its overall Quality Strategy in 2016.     Many hospitals and healthcare systems that have prioritized patient safety are building patient and family advisory councils (PFACs) or other infrastructure that embed PFE.  However, many hospitals and clinical practices have yet to incorporate robust PFE into their patient safety programs.
System improvement and patient advocates also underscore the importance of education about PFE in multiple settings, including professional education in medicine, nursing, pharmacy and other healthcare fields.  General education about using healthcare safely also is being advocated, in primary or secondary school curricula as well as libraries, online forums or other venues for adult education. All educational efforts should address the needs of vulnerable populations, including those with low literacy or health literacy as well as those with disabilities, cognitive or mental health challenges, limited access to or inability to afford healthcare services, and limited access to or inability to use information technology.

 Leadership Plan

 To successfully engage patients and families in safety at the point of care and in safety improvement work, a healthcare organization must commit to and invest in a culture of safety and transparency.  This begins with and is dependent upon governance and executive leadership that also is committed to and engaged in achieving zero harm.  A robust PFE program can help organizational leaders both build and sustain the culture of safety.  For these reasons, the Leadership Plan for PFE incorporates and builds on the Culture of Safety Leadership Plan set forth in APSS #1. 
Leadership Plan for Culture of Safety (incorporated from APSS #1):
* Hospital governance and senior administrative leadership must commit to becoming aware of this major performance gap in their own organizations. Senior leaders cannot merely be "on board" with patient safety--they must own it.
* Hospital boards must focus on safety and quality, not just finances and strategy. Research demonstrates that patient outcomes suffer when boards do not make safety a top priority. 

* Hospital governance, senior administrative leadership, and clinical/safety leadership must close their own performance gap by implementing a proactive, comprehensive approach to addressing the culture of safety.
* Healthcare leadership (clinical/safety) must reinforce their commitment by taking an active role in championing process improvement; giving their time, attention and focus; removing barriers, and providing necessary resources.
* Healthcare Leadership must demonstrate their commitment and support by shaping a vision of the future, providing clearly defined goals, supporting staff as they work through improvement initiatives, measuring results, and communicating progress towards goals.
* There are many types of leaders within a healthcare organization, and in order for process improvement to truly be successful, leadership commitment and action are required at all levels. The Board, senior leadership, physicians, pharmacy and nurse directors, managers, unit leaders and patient advocates all have important roles and need to be engaged in specific behaviors that support staff to provide safer care.
* Safety culture and performance must be valued and reflected in compensation plans so that leaders have direct personal accountability for results. 

Additional Leadership Plan Components for PFE:
* Ensure your organization has a clear definition of PFE.
* Discuss PFE with your senior leadership team so that they understand that it matters to you and the organization.
* Elicit input from your board, your staff and representative patients and families about what your organization will look like if it is successfully engaging patients and families.
* Make improving PFE an organizational goal.
* Establish infrastructure in your organization that creates pathways for PFE input in safety improvement work.
* Allocate time in meetings with senior leadership, staff and the board to hear and tell stories about engagement success and shortcomings.

Practice Plan

Healthcare organizations should consider using the Carman framework or an alternative framework (see list above in the Performance Gap section) to implement a PFE program that engages patients or their family members at two levels:
I. Avoiding preventable harm in their own care [Level: Direct Care], and
II. Serving as organizational advisors on operational improvement work or as contributors to Board of Governors oversight on patient safety [Level: Organizational Design and Governance].
Healthcare organizations should consider establishing a PFE infrastructure that aligns with and advances the innovation currently being driven by CMS.  In hospitals and multi-site systems, this includes deploying a five part PFE practice plan:
1. Use of a checklist during the patient discharge process for all elective hospital stays to ensure reliable transmission of discharge instructions [Level: Direct Care];
2. Performance of safety huddles and nurse shift changes at the patient bedside including active patient participation in the process [Level: Direct Care];
3. Assignment of PFE responsibility as the function of a hospital organizational unit or the job description of at least one hospital employee [Level: Organization Design & Governance];
4. Establishment of a Patient and Family Advisory Council or equivalent structure to include patient input into hospital safety and quality improvement work [Level: Organization Design & Governance];
5. Appointment a person who identifies primarily as a patient or family member to the hospital Board of Governors or a Board-level committee with oversight of safety and quality [Level: Organization Design & Governance].
In non-acute care clinics or other ambulatory care delivery sites, a six part PFE practice plan should be considered.
1. Use of a tool to assess patient readiness to be "activated" as a partner in the patient's own care [Level: Direct Care];
2. Use of a tool to assess a patient's degree of health literacy [Level: Direct Care];
3. Use of a tool to support shared decision-making between patients and their providers;
4. Establishment of a process to support medication use [Level: Direct Care];
5. Use of a technological platform to communicate with or provide information to patients [Level: Direct Care]; and
6. Establishing a Patient and Family Advisory Council or equivalent infrastructure to include patient input into safety improvement work [Level: Organization Design & Governance] [Level: Organization Design & Governance].
At the Organizational Design & Governance level, healthcare organizations should consider engaging users of care in improvement efforts and measure progress in one or more of the following areas:
• Adverse Drug Events
• Catheter-Associated Urinary Tract Infections
• Central Line Associated Blood Stream Infections
• Injuries from Falls and Immobility
• Obstetrical Adverse Events
• Pressure Ulcers
• Surgical Site Infections
• Venous Thromboembolism
• Reducing Hospital Readmissions
• Clostridium Difficile (c-diff)
• Airway Safety
• Severe Sepsis and Septic Shock
• Hospital Acquired Acute Renal Failure
• Ventilator-Associated Pneumonia
• Effective Management of Critical Test Results
• Iatrogenic Delirium
• Procedural Harm
• Undue Exposure to Radiation
• Failure to Rescue
• Hospital Culture of Safety
• MRSA
• Pain management