A Closer Look at The Center for Medicare & Medicaid Services’ Proposed Patient Safety Structural Measure

Patient safety is a critical component of healthcare quality. Despite significant advancements, preventable harm remains a significant concern in healthcare settings. The Centers for Medicare & Medicaid Services (CMS) has proposed a new Patient Safety Structural Measure (PSSM) to improve patient safety in hospital settings. This new quality measure will assess how hospitals implement safety improvement systems and evaluate hospital leadership’s commitment to patient safety. We at Beterra believe this is a proactive step towards continuous improvement and high reliability in patient care, and we are confident that it will significantly enhance patient safety.

A Quick Summary

In the proposed fiscal year (FY) 2025 Hospital Inpatient Prospective Payment (PPS) rule, CMS will introduce the Patient Safety Structural Measure (PSSM) for the Hospital Inpatient Quality Reporting (IQR) Program and the PPS- Exempt Cancer Hospital Quality Reporting (PCHQR) program. The PSSM is an attestation-based measure, meaning hospitals must affirmatively attest to having specific structures and practices in place that prioritize patient safety. The proposed reporting period will start in Calendar Year (CY) 2025 for Financial Year (FY) 2027 payment determination.

Crafted with input from a Technical Expert Panel and grounded in the “Safer Together: The National Action Plan to Advance Patient Safety,” it consists of the below five domains.

1. Leadership Commitment to Eliminating Preventable Harm
2. Strategic Planning & Organizational Policy
3. Culture of Safety and Learning Health System
4. Accountability & Transparency
5. Patient & Family Engagement.

Each domain contains multiple statements that capture the essential structural and cultural elements of patient safety. Hospitals must affirmatively attest to all statements within a domain to receive a point for that domain. The maximum score is five (5) points, with one (1) point available per domain.  Under this proposal, CMS will publicly report the hospital’s performance score on these measures annually on Care Compare starting in the fall of 2026.

Updated: August 9, 2024

The Five Domains: A Deeper Dive on the Domains

The team at Beterra, working with regulatory experts, has summarized the PSSM’s five domains so that your organization can implement strategies and programs that align with this requirement.

Leadership commitment to eliminating preventable harm: This domain is aimed at the hospital leadership’s ability to demonstrate that it can prioritize and champion patient safety initiatives. It holds leadership teams accountable for providing appropriate resources to support safety initiatives. It also ensures that safety-related topics and metrics are consistently prioritized and transparently communicated across the organization. The key components include:

1. Prioritization of Safety by the Governing Board: The senior governing board must prioritize safety as a core value and hold hospital leadership accountable for patient safety outcomes. Patient safety metrics should be integrated into annual performance reviews and compensation for leadership.
2. C-Suite Oversight and Accountability: C-suite executives must oversee system-wide safety assessments and initiatives. Specific improvement plans and metrics should be developed and shared widely across the hospital and governing board.
3. Resource Allocation: The governing board, in collaboration with leadership, must ensure adequate resources are allocated to support patient safety, including equipment, training, systems, personnel, and technology
4. Transparency and Communication: Reporting on patient and workforce safety events and initiatives should account for at least 20% of the regular board agenda and discussion time. Serious safety events resulting in significant morbidity, mortality, or other harm must be reported to C-suite executives and board members within three (3) business days.

Strategic Planning & Organizational Policy: This domain addresses how the hospital’s strategic plan emphasizes patient safety as a core value aiming for “zero preventable harm” while also addressing safety disparities. It includes several written policy components that promote a just culture, workforce safety initiatives, patient safety training, and regular competency assessments and action plans. The key elements include:

1. Strategic Commitment to Patient Safety: The hospital must have a strategic plan that publicly shares its commitment to patient safety as a core value, outlining specific safety goals and associated metrics, including the goal of “zero preventable harm.”
2. Addressing Safety Disparities: Hospital safety goals must include metrics to identify and address disparities in safety outcomes based on patient characteristics determined to be most important for the specific populations served.
3. Cultivating a Just Culture: The hospital must implement written policies and protocols to cultivate a just culture, balancing no blame and appropriate accountability, reflecting the distinction between human error, at-risk behavior, and reckless behavior.
4. Comprehensive Patient Safety Training: The hospital must require implementation of a patient safety curriculum and competencies for all clinical and non-clinical staff, including C-suite executives and governing board members, with regular assessments and action plans for advancing safety skills.
5. Workforce Safety Action Plan: The hospital must have an action plan for workforce safety with improvement activities, metrics, and trends addressing slips/trips/falls prevention, safe patient handling, exposures, sharps injuries, violence prevention, fire/electrical safety, and psychological safety.

Culture of Safety and Learning Health System: This domain enhances safety culture and continuous learning. Organizations can meet this requirement by using safety culture surveys and sharing results with staff and the board for targeted interventions. Organizations should have patient safety dashboards that track and benchmark metrics to improve issues like medication errors and infections. High-reliability practices include event root cause analyses, safety huddles, leadership rounding, event tracking, technology integration, improvement methods, staff training, and participation in safety networks.

1. Safety Culture Surveys: Organizations must conduct a hospital-wide culture of safety survey using a validated instrument annually or every two years with pulse surveys on target units during non-survey years. They must share the survey results transparently with the governing board and hospital staff and use the findings to inform unit-based interventions.
2. Serious Safety Event Analysis: A dedicated team must analyze serious safety events using evidence-based approaches such as root cause analysis to identify underlying causes and contributing factors. They must develop and implement corrective actions to prevent recurrence and share the lessons learned with the organization.
3. Patient Safety Dashboard: A patient safety dashboard must track metrics and benchmarks against external standards (such as CMS Star Ratings or other national benchmarks), guiding improvement efforts for issues like medication errors and infections. The data on the dashboard must be regularly updated and shared with staff and leadership and should be used to guide targeted improvement initiatives.
4. High-Reliability Practices: Organizations must implement at least four high-reliability practices to enhance safety culture and continuous learning. They may choose the four practices: Safety Huddles, Leadership Rounding, Safety Data Infrastructure & Technology Integration, Adoption of Team Communication training, Improvement Methodologies Implementation, and Human Factors Engineering.
5. Participation in Safety Improvement Networks: Organizations must participate in a large-scale learning network for patient safety improvement, share data on safety events and outcomes, and implement best practices from these networks.

Accountability & Transparency:  The proposed PSSM’s fourth domain emphasizes how healthcare organizations operate with accountability and transparency regarding safety. The requirements include operating a confidential safety reporting system with a robust feedback loop. Tracking and public display of certain patient safety metrics, along with evidence-based communication and resolution programs (such as AHRQ’s CANDOR), are also warranted. Key components of this domain include:

1. Confidential Safety Reporting System: Organizations must operate a confidential safety reporting system that enables staff to report events and concerns anonymously, with a feedback loop. Organizations must regularly review and analyze these reports to identify trends and areas of improvement.
2.  Reporting to Patient Safety Organizations:  Hospitals must report serious safety events, near misses, and precursors to a Patient Safety Organization (PSO) listed by the Agency of Healthcare Research and Quality (AHRQ). They must use the feedback from the PSO to inform safety improvement initiatives.
3. Patient Safety Metrics and Public Display: Organizations must develop, track, and publicly display a set of patient safety metrics to promote transparency and accountability. These metrics should be reported to all clinical and non-clinical staff and made public in hospital units so that staff, patients, families, and visitors can see them.
4. Evidence-Based Communication and Resolution Program: Hospitals have a defined evidence-based communication and resolution program, such as AHRQ’s CANDOR toolkit that contains and covers harm event identification, open communication with patients and families about the harm event, event investigation, Care for caregivers, financial and non-financial reconciliation, and ongoing patient-family engagement and support. Hospitals must use standard measures to track the performance of their communication and resolution programs and report these measures to the governing board at least quarterly.

Patient and Family Engagement: The proposed PSSM emphasizes engaging patients and families in safety initiatives by ensuring diverse representation on the Patient and Family Advisory Council, integrating community input into safety activities, and including patient feedback on safety events and discrimination. Patients should have access to their medical records with support for corrections, and hospitals should support family involvement in care and encourage 24-hour visitation where feasible. The key components of this domain are:

1. Diverse Representation on Patient and Family Advisory Council (PFAC): Hospitals must ensure diverse representation on their PFAC and integrate patient, family, caregiver, and community input into safety-related activities. This could include representation at board meetings, consultation on safety goal setting and metrics, and participation in safety improvement efforts.
2. Enhanced Access to Medical Records: Hospitals must implement user-friendly systems to access medical records and clinician notes and support patients culturally and linguistically in reviewing and correcting their records.
3. Incorporating Patient and Caregiver Input: Hospitals must actively incorporate patient and caregiver input about patient safety events or issues, including patient submissions of safety events, safety signals from complaints, patient safety experience data, and patient reports of discrimination.
4. Family Involvement in Care: Hospitals must support the presence of family and other designated persons as essential care team members. Hospitals must encourage engagement in bedside rounding, shift reporting, and discharge planning. Hospitals should promote 24-hour visitation when feasible.

Conclusion and A Call to Action.

We at Beterra believe the proposed Patient Safety Structural Measure (PSSM) represents a significant step towards improving the safety and quality of the American healthcare system.  By focusing on these comprehensive structural reforms, healthcare organizations can create environments where safety and overall quality of care are significantly enhanced.

We urge healthcare leaders to approach this as an opportunity for improvement for themselves and their respective organizations. We recommend you continue implementing and acting on safety and culture improvement systems and activities, consistently delivering safe, high-quality, and equitable care.

About Beterra

Beterra is a healthcare solutions company focused on patient safety culture and unit-based improvement. Our solutions help clients accelerate improvement via collection, analysis, sense-making, patient safety, and quality data utilization.