Implementing the Centers for Medicare & Medicaid Services (CMS) Patient Safety Structure Measure - CME Paid Option-Patient Safety Structural Measure

Video Transcription

Video Summary

The webinar, led by Kathy Collins, Clinical Improvement Consultant at Compass Healthcare Collaborative, introduced the new CMS Patient Safety Structural Measure (PSSM) required in fiscal year 2025 under the Hospital Inpatient Quality Reporting program. It is an attestation-based measure focusing on whether hospitals have structures and cultures prioritizing patient safety, assessed across five domains: 1) leadership commitment to eliminating preventable harm, 2) strategic planning and organizational policy, 3) culture of safety and learning health systems, 4) accountability and transparency, and 5) patient and family engagement. Each domain includes multiple specific elements that hospitals must fully meet to earn credit.<br /><br />The session emphasized developing strong patient safety programs and shared examples of best practices such as board engagement, public sharing of safety performance, implementing just culture policies, educating all staff including executives, data-driven safety monitoring, robust event analysis, confidential reporting systems, and comprehensive patient-family involvement.<br /><br />Reporting will be done annually via the NHSN starting spring 2026 for the 2025 year, with payment updates tied to compliance for acute care hospitals (voluntary for Critical Access Hospitals). Challenges with domains like accountability and patient-family engagement were acknowledged. Participants were encouraged to collaborate, share successes and barriers, and plan for upcoming in-depth webinars. Resources and technical assistance were provided to support hospitals in preparation and implementation of the PSSM.

Keywords

Patient Safety Structural Measure

PSSM framework

Leadership domain

Healthcare safety culture

Senior leadership accountability

Governing boards

Patient harm stories

Safety resource allocation

Continuous improvement

CMS Patient Safety Structural Measure

Hospital Inpatient Quality Reporting

patient safety programs

leadership commitment

culture of safety

accountability and transparency

patient and family engagement

NHSN reporting

just culture policies