The Roadmap to Health Care Safety for Massachusetts is a strategic plan to break new ground on safety through investment and change management.

A new vision for the Commonwealth

The Roadmap to Health Care Safety for Massachusetts sets five goals that will be reached through a sustained, collective statewide effort among provider organizations, patients, payers, policymakers, regulators, and others. Strategies and action steps for advancing these goals adhere to seven guiding principles:

  • Move the health care system toward a mindset of zero tolerance for defects that can result in physical or emotional harm to patients, families, and staff;
  • Support approaches to continuous, proactive safety improvement that break down silos and enable all stakeholders to carry out their respective roles;
  • Promote a “just culture” by adopting a fair and consistent approach to safety improvement that fosters psychological safety in the health care workforce and holds leadership accountable for breakdowns and shortfalls;
  • Advance health equity through the elimination of disparities in safety and quality outcomes on the basis of race, ethnicity, age, disability, sex, gender, language, and economic factors;
  • Encourage an approach to health care and safety that maximizes the benefits of co-production, recognizing that patients and families provide expertise essential to person-centered care;
  • Reduce low-value administrative burdens; and
  • Remove all forms of waste from work, making it easier to do the right thing.

Read the Roadmap and executive summary.

All leaders of health care provider organizations across the continuum of care make safety a core value and enduring priority, continuously act to advance safety culture and operations, and are accountable for safety performance.


1.1 Increase the proficiency of board members, executive leaders, and owners on leading and sustaining safety culture and continuous improvement systems through curricula, peer learning opportunities, toolkits, and other resources.

1.2 Establish educational standards on safety for leaders and governing bodies.

1.3 Recognize board members, executive leaders, and owners who achieve high levels of competence and commitment to safety for patients, families, and the workforce.

1.4 Reward exemplary performance and progress on continuous safety improvement through reduced liability insurance premiums and higher reimbursement rates.

All provider organizations have systems in place that enable leaders, managers, clinicians, and staff to continuously identify safety issues, resolve problems, integrate their operations with safety strategy and plans, and engage patients and families as partners in the work.


2.1 Support provider organizations as they implement appropriately scaled Continuous Improvement Systems within a culture of safety through a coordinated program of education, technical assistance, and experiential learning.

2.2 Establish standardized measure sets and self-assessment tools for use by provider organizations across the continuum of care in tracking their own safety outcomes and the effectiveness of their safety processes and structures.

2.3 Leverage new technologies, such as automated electronic health records surveillance, to detect and enable a nimble response to safety risks and events, inform improvement work, and reduce future harm.

2.4 Strengthen Patient and Family Advisory Councils (PFACs) to foster diverse representation, more patient and family involvement, and deeper partnership with the community on safety improvement.

2.5 Establish educational standards on safety for managers, clinicians, and staff in clinical and nonclinical roles.

2.6 Create an accessible statewide health care safety curriculum that fosters a shared understanding of fundamental principles and practices across diverse roles and care settings and enables greater engagement in improvement work by all members of the health care workforce.

2.7 Advocate for health care safety to be integrated into the curricula of training programs for the health professions.

All patients and families are engaged and supported to avoid preventable harm in their own care, and receive timely, transparent, and continuing communication and support when things go wrong.


3.1 Raise public awareness of health care safety challenges and initiatives.  

3.2 Boost health care literacy to enable patients, including members of historically underserved or marginalized communities, to avoid preventable harm in their own care and to participate in the safety improvement work of provider organizations.

3.3 Assist patients and families who experience error, harm, or trauma in their care through programs offering culturally competent emotional support and communication, apology, and resolution as appropriate. 

3.4 Build the skills of health care professionals to communicate openly and effectively with diverse patients and families, especially in instances of medical error or harm.

All provider organizations strive to eliminate undue workplace stresses and conditions that impact patient safety and the safety and well-being of the workforce, and clinicians and staff have the psychological safety and support they need to continuously engage in safety improvement.


4.1 Through provider organizations’ Continuous Improvement Systems, encourage routine clinician and staff observations and contributions to address patient and workforce safety risks including unsafe cultures and ineffective workflows.

4.2 Support the development of a fair and just culture and psychological safety within a culture of safety to promote clinician and staff reporting of events and near misses.

4.3 Expand programs that offer emotional support, learning, and well-being for clinicians and staff following safety or other traumatic events.

4.4 Leverage current national and statewide health care workforce well-being efforts that advance a structured approach to reducing stress, moral injury, burnout, and compassion fatigue.

The state’s health care safety data systems are optimized and harmonized, and provide timely and useful information about providers’ safety performance for providers, policymakers, and the public.


5.1 Develop measure sets for benchmarking health care safety outcomes, processes, and structures in settings across the continuum of care.

5.2 Improve state health care safety data systems by streamlining reporting processes, addressing data duplication and gaps, ensuring that data can be stratified by race, ethnicity, and other characteristics, and promoting appropriate data analytics and sharing.

5.3 Publish dashboards containing timely, relevant, and actionable information about health care safety outcomes, processes, and structures in settings across the care continuum.

5.4 Report annually on the state of health care safety in Massachusetts, assessing progress toward the five Roadmap to Health Care Safety goals and identifying opportunities for continuous improvement at the state and provider levels.