Strengthening Clinical Safety Reliability Through CMS SAFER Guide Assessment

How Mount Sinai Medical Center streamlined its CMS SAFER Guide self-assessment process, strengthening EHR safety documentation, cross-departmental collaboration, and long-term regulatory readiness across all nine guides.

Client

Mount Sinai Medical Center, the largest independent not-for-profit teaching hospital in Florida, has long invested in strengthening digital health, EHR resilience, and clinical safety for the South Florida communities it serves.

When the Centers for Medicare & Medicaid Services (CMS) shifted requirements around SAFER Guide attestation, Mount Sinai turned to their trusted EisnerAmper advisors for support to help them facilitate, organize, and document a complex regulatory self‑assessment that is a baseline requirement adopted by healthcare providers nationally.

The Importance of SAFER Guides

The Centers for Medicare & Medicaid Services (CMS) originally released the SAFER (Safety Assurance Factors for EHR Resilience) Guides in 2016, designed to improve the safety and safe use of electronic health record technologies. In 2022, CMS made it mandatory for hospitals to attest annually that they had completed a SAFER assessment for the calendar year. Further, in 2024 the Guides were refined with a focus on alignment and adding safer adoption of AI.

Beginning in 2024, CMS added a corresponding payment adjustment for hospitals that report they have not completed the assessment. This update, reflecting CMS’s ongoing efforts to enhance EHR safety and transparency, created a renewed sense of urgency for organizations like Mount Sinai to ensure their assessment processes were well structured and thoroughly documented.

Key areas of focus:

The Challenge

Mount Sinai was responsible for completing the assessment of nine (9) SAFER Guides for the 2025 calendar year. Each guide includes dozens of recommended practices (165 in total) across categories that are centered around using healthcare information technology (IT) safely.

These practices range from redundancy of critical hardware to optimizing safety during clinical decision-making and order-entry processes. Each recommended practice includes a rationale, risk explanation, and example scenarios for clarity to perform the assessment.

Bringing together executive leadership, including the Director of Clinical Informatics, Chief Nursing Informatics Officer, and Chief Medical Officer

Understanding what documentation counts as supporting evidence

Ensuring the assessment would be fully completed within the required timeframe

Working through the guidance with clarity and confidence (in interpreting the assessment criteria)

Approach

1. Translate Detailed Guidance into Actionable Steps

Our EisnerAmper team gathered the recommended practices and correlated them beyond the examples CMS provided with controls, which are built on CMS examples, industry best practices, and EisnerAmper’s own experience conducting assessments. These controls (which are collated uniquely in the industry by EisnerAmper) gave Mount Sinai a clearer understanding of how to evaluate each recommended practice and present evidentiary supporting documentation for the implementation status reported.

2. Organize and Facilitate Assessment Meetings

With an excellent focus on project management and interpretation of the assessment criteria, Mount Sinai made sure to bring the right multidisciplinary team together. The EisnerAmper engagement team then partnered with this group to:

Run meetings and assign roles & responsibilities
Bring clarity to each recommended practice evaluated
Ensure all details from the SAFER guides were considered

3. Organize Documentation Process

As a unified front, the Mount Sinai and EisnerAmper teams then:

Reviewed evidentiary documentation planned to be included in the report-out
Mapped documentation to the appropriate practice while highlighting gaps
Proposed structuring to assessment outputs in a way that was defensible to CMS or any third party such as re-insurers

4. Leveraged Domain Knowledge and Past Experience

Because EisnerAmper has completed full assessments for other hospitals, our findings were informed by:

Real‑world interpretations of CMS expectations
Best‑practice evidence standards
Common organizational pitfalls (e.g., siloed assessments vs. multidisciplinary ones)

Results

Mount Sinai completed its 2025 calendar year SAFER assessment, positioning the organization to meet CMS attestation requirements.

The assessment also became more comprehensive, organized, and defensible, setting Mount Sinai up to successfully maintain the process year‑over‑year.

Additionally, Mount Sinai:

Improved supporting documentation consistency from prior years

Benefited from cross‑departmental and multi-disciplinary collaboration

Reduced the time required to complete the assessment

Conclusion

With patient safety as a core priority, Mount Sinai approached the SAFER assessment as an opportunity to strengthen care delivery. They not only met regulatory requirements but expanded to proactive risk management to protect providers and patients. EisnerAmper supported this mission by simplifying CMS expectations, accelerating evidence development, and aligning clinical and operational stakeholders for sustained safe care delivery. Mount Sinai is now building safer processes at scale, setting themselves up to continue delivering top-notch patient care.

When health systems prepare for SAFER assessments to navigate EHR‑safety compliance, EisnerAmper can help, from advisory support to full technology‑enabled assessments. By leveraging the SAFER platform, EisnerAmper has helped health systems reduce administrative burden by up to 50%, achieve CMS compliance, and implement proven controls for EHR risk mitigation.

The SAFER platform provides a clear remediation roadmap to strengthen EHR resiliency and delivers leadership dashboards to drive informed decision-making, ultimately enhancing patient safety while helping organizations reduce medical malpractice exposure and strengthen defensibility.

Contact Us

Discover how EisnerAmper helped Mount Sinai Medical Center streamline its CMS SAFER Guide self-assessment process, strengthening EHR safety documentation, cross-departmental collaboration, and long-term regulatory readiness across all nine guides.