Quality Quarterly

New CMS Patient Safety Structural Measure Hinges on 25 Strategies, Practices to Prioritize Safety

Key Takeaways: 

  • Centers for Medicare & Medicaid Services (CMS) Patient Safety Structural Measure (PSSM) is intended to improve hospital safety by focusing on structural elements that support a culture of safety 
  • Reporting begins in FY 2025 
  • Hospital Quality Institute has a leading-edge program to help hospitals meet the new requirements 

The Centers for Medicare & Medicaid Services’ (CMS) new Patient Safety Structural Measure — inaugurated Aug. 1 as part of its final rule for the fiscal year 2025 hospital inpatient prospective payment system — is an attestation-based measure indicating whether hospitals are prioritizing patient and employee safety.

The PSSM is an attestation-based measure indicating whether hospitals are prioritizing patient and employee safety. Hospitals are asked to attest to the use of 25 proven strategies and practices that support systemic and cultural improvements in safety. Included in the measure is the implementation of a communication and resolution program (CRP), such as CANDOR, consisting of the following elements: 

  • Harm event identification  
  • Open and ongoing communication with patients and families about the harm event  
  • Event investigation, prevention, and learning  
  • Care-for-the-caregiver  
  • Financial and non-financial reconciliation  
  • Patient-family engagement and ongoing support  

Time is of the essence for hospitals. Mandatory reporting on the new measure starts with Calendar Year 2025, and—beginning in 2027—CMS will reduce payments to hospitals that have not submitted this data.  

Hospitals that have yet to implement a CRP can find support through HQI’s state-of-the-art CRP program, HQI Cares: Implementing BETA HEART®. This program provides a proven path to meeting all of the above CMS-specified elements. It guides hospitals to build a true culture of safety focusing on key goals:   

  • Providers and staff feel empowered to report errors, harm incidents, and near misses without fear of reprimand or punishment.  
  • Reporting and communication about patient harm is proactive, empathic, and transparent. 
  • Event reviews focus on system redesign instead of individual mistakes. 
  • Patients, families, and staff are reliably supported all along the way. 

For more information about HQI Cares: Implementing BETA HEART®, contact Boris Kalanj, HQI’s director of programs at bkalanj@hqinstitute.org