The Centers for Medicare & Medicaid Services (CMS) has introduced a significant new requirement for hospitals as part of the FY2025 final rule. Hospitals participating in the Hospital Inpatient Quality Reporting (IQR) program are now required to report yes or no annually to a 25-point comparison of how their hospitals operate compared to CMS’s vision of patient safety excellence.
The comparison is organized into five domains, each with five “measures,” for a total of 25. Hospitals that can say “yes” to all measures in all domains will demonstrate that they have prioritized patient safety with evidence-based programs aimed at reducing preventable harm.
The Five Domains of PSSM
1. Leadership Commitment to Eliminating Preventable Harm
- Hospital leadership, including senior governing boards, must be accountable for patient safety outcomes. Safety should be integral to strategic, financial, and operational decisions, and leaders must foster a culture that places patient safety at the forefront.
2. Strategic Planning and Organizational Policy
- Hospitals must develop strategic plans that highlight patient safety as a core value, set specific safety goals (like “zero preventable harm”), and employ written policies that cultivate a just culture.
3. Culture of Safety & Learning Health System
- A hospital must foster a proactive culture of safety that encourages learning and improvement across the entire organization. This requires integrating evidence-based practices, conducting regular safety surveys, and analyzing serious safety events to develop actionable improvements.
4. Accountability and Transparency
- Hospitals must promote transparency around patient safety, encouraging the reporting of safety events and ensuring that this information is shared without fear of retribution. Hospitals should have clear communication strategies and systems in place to handle harmful events effectively.
5. Patient and Family Engagement
- Engaging patients, families, and caregivers in safety processes is crucial for delivering safer care. Hospitals are encouraged to involve them in safety-related activities and ensure open communication channels are in place for reviewing and addressing safety concerns.
How Does PSSM Work?
Hospitals will report their adherence to the CMS PSSM through the National Healthcare Safety Network (NHSN) platform. Detailed guidelines and additional resources are being developed and will be made available to assist hospitals in evaluating their safety activities across the five domains.
Conclusion
The CMS Patient Safety Structural Measure represents a significant step forward in persuading hospitals to prioritize patient safety at every level.
PSSM provides hospitals with a standardized guide to patient safety that comprehensively covers leadership, strategy, culture, accountability, and patient engagement. It should drive all hospitals to raise their investments in patient safety to a similar standard rather than choosing to follow only a subset of best practices.
Nurses and providers across the nation should also find less variation in the standard of care they provide from hospital to hospital.
The result is an improved capability to provide quality care that protects patients, benefits healthcare providers, and reduces the waste in our healthcare system from the extra care required for harmed patients.
Hospitals can use resources like SafeQual to reduce the additional efforts required of the CMS PSSM to engineer a swifter environment for safety, quality, risk, and compliance activities. An environment that truly gives weightage to avoiding patient and employee harm across our nation.
For a more in-depth description of CMS PSSM, follow the link below: https://www.safequal.net/cms-patient-safety-structural-measure/
