Annual Acute Care Hospital Patient Safety Attestation (2026) Survey

Thank you in advance for completing this survey regarding your facility or facilities.

This survey will confirm that your facility/facilities meet/s the Patient Safety Standards required under 45 CFR 156.1110.

This federal regulation applies to hospitals with more than 50 beds and requires that contracted hospitals either utilize a patient safety evaluation system or have implemented evidence-based initiatives to improve healthcare quality.

If you represent multiple facilities within the same hospital system and share patient safety arrangements, complete only ONE survey for the entire system. If you are attesting for multiple hospitals, list all hospital names and their 6-digit CMS Certification Numbers (CCNs) in Question #4 (below), separated by semicolons (;).

If your facility is not part of a larger hospital system or a hospital in your system uses different patient safety arrangement, please complete this attestation individually.

Please complete all fields in this survey unless otherwise noted, including hospital name(s) and CCN number(s). We are unable to consider your attestation complete without the required information.

Your timely response helps ensure compliance and supports our shared commitment to patient safety.

1.If you are not the right person to confirm your facility's/facilities' patient safety protocols, please provide the correct person’s name, title, and email. If the correct person has already received this survey, you can skip this question.(Required.)

Name:

Title:

Email Address:

2.Choose ONE of the following:(Required.)

Your facility/facilities:
1. Use/s a patient safety evaluation system (for reporting to or by a Patient Safety Organization, “PSO”), AND
2. Has/have a process for comprehensive, person-centered hospital discharge to improve care coordination and quality.
A list of PSOs is available at https://pso.ahrq.gov/pso/listed and is updated weekly.

Your facility/facilities use/s an evidence-based patient safety initiative to improve health care quality through the collection, management and analysis of patient safety events that reduces all cause preventable harm, prevents hospital readmission, or improves care coordination.

3.Based upon your answer to question #2, provide ONE of the following:

The name of the PSO (a list of PSOs is available at https://pso.ahrq.gov/pso/listed)

Enter a description of the evidence-based patient safety initiatives your facility/facilities utilize/s.

(Required.)

4.The undersigned attests that the above information submitted in response to Horizon’s Blue Cross Blue Shield of New Jersey’s request is true, correct, and complete. I attest that I have the appropriate authority to complete this attestation on behalf of the hospital facility/facilities. I understand that if any of this information is subsequently found to be false, misleading, or incomplete, that I will take action to correct and submit such information to Horizon BCBSNJ. I also agree to provide updated information on an ongoing basis as requested. Finally, I understand that the information provided on this attestation may be shared with appropriate State and federal agencies, upon their request.

By typing my name below, I understand and agree that this typed name serves as my electronic signature and has the same legal force and effect as a manual signature. I consent to using this electronic signature for this document and agree that it is binding for the purposes of this agreement.

*If you are attesting for multiple hospitals within a system, please list all the hospital names and 6-digit CMS Certification Numbers (CCNs) in the fields below, separating multiple values using a semicolon (;).(Required.)

Date

Signature (typed name)

Title

Signatory's Email Address

Hospital/s Name/s

Hospital/s CCN/s

Current Progress,

0 of 4 answered