Patient Safety Structural Measure

Here is the Patient Safety Structural Measure Overview. This presentation will provide an overview of the CMS Patient Safety Structural Measure. The objectives are as listed here. We're going to review the five domains within the PSSM, discuss the expected release date in the NHSN application, and define the reporting timeframe and scoring. The Patient Safety Structural Measure is an attestation-based measure designed to capture essential actions taken by hospitals to enhance patient safety. This measure focuses on several key aspects. It evaluates whether hospitals demonstrate a systems-based approach to safety, whether their leaders prioritize and champion safety initiatives, and whether they meaningfully engage a cross-section of patients and families as partners in safety. Additionally, it assesses whether their practices reflect a culture of safety and whether there is an atmosphere of continuous learning and improvement within the organization. To effectively assess these elements, the Patient Safety Structural Measure is organized into five priority domains. Each of these domains contains five statements that aim to capture the most critical structural and cultural components of patient safety. This measure is required for hospitals participating in the Hospital Inpatient Quality Reporting Program and the Prospective Payment System Exempt Cancer Hospital Quality Reporting Program. The data submission period for both programs will take place from April 1st to May 15th of 2026. And during this period, facilities will need to attest to the structures, systems, and processes that were in place throughout the calendar year 2025, specifically from January 1st to December 31st of 2025. The measure is comprised of a set of complementary attestation statements that aim to capture actions that advance safety practices and outcomes. These attestations are organized into five priority domains. Leadership Commitment to Eliminating Preventable Harm, Strategic Planning and Organizational Policy, Culture of Safety and Learning Health Systems, Accountability and Transparency, and Patient and Family Engagement. Each of the five domains consists of five attestation statements that hospitals must respond to. A hospital will evaluate and determine whether it engaged in each of the statements that compromise a domain. If a hospital can respond yes to any of the statements at any time during the reporting period, it meets the requirement for that particular statement. But now let's talk about how this impacts the overall assessment. If a hospital can affirmatively attest yes to all statements within a domain, it fully satisfies that domain's requirements. However, it's crucial to note that hospitals cannot receive partial points for a domain. This means that only a complete affirmation to all statements will qualify for a point. So in summary, for each domain, hospitals must attest yes to all five statements to earn a point. This structure allows hospitals to potentially earn a maximum of five points, one for each domain, by fully affirming their engagement with all statements. So what happens if multiple hospitals share a single CCN? In that case, all facilities sharing the same CCN will need to satisfy domain criteria for a positive attestation. If multiple NHSN org IDs under a shared CCN report different score values, CMS will apply the lowest facility score of the org IDs to the CCN. So here's an example here when scoring a single facility under a single CCN. Pretty simple, right? You will see that there is only one facility. Since there's only one facility, the score for will be the final CCN score here. When multiple facilities operate under one CCN, it is essential that each individual hospital completes the patient safety structural measure as each facility will be scored separately. However, it's important to know how that final score for the entire CCN is determined. The overall score for the CCN will be based on the lowest score reported by any of the member facilities. This means that even if one facility performs exceptionally well, the final score for the CCN will be impacted by the lowest scoring facility. So we're going to look at that scoring example here. So there are three different facilities in this example that share that single CCN, you see. The first facility has a score of five, the second a score of three, and the third a score of four. So that final CCN score is three, which reflects the lowest score reported by the facilities that share this CCN. And there you'll see that that's the final CCN score is three. We're going to do an all check to make sure that everyone, that what I did, I did my job today here in giving an overview of this measure. So Hospital A and Hospital B reports to NHSN under a single CCN. Hospital A earns five points and Hospital B earns three points. The score for the CCN is three. Is this true or false? And I'm seeing a lot of A's, which is the answer means it's true. So I think I did my job for this hot topic today. So everyone give yourselves a pat on the back for getting that answer correct. And we will move on to the next hot topic here. The resources here for this, you will find them if you want to look up any resources for this measure are found here. And again, if you have any questions, please contact the NHSN help desk and we'll be happy to help you.