Patient Safety Structural Measures (PSSM) Toolkit
As part of the FY2025 final rule, CMS is requiring hospitals to participate in the Hospital Inpatient Quality Reporting (IQR) program to report on the Patient Safety Structural Measure (PSSM).
Structural measures provide a way for hospitals to address a topic for which no outcome measure exists. CMS expects that by attesting to these measures, hospitals will develop evidence-based programs and processes to support improvements in high impact areas such as leadership commitment to eliminating preventable harm, strategic planning and organizational policy, culture of safety and learning health system, accountability and transparency, and patient and family engagement.
This toolkit provides materials to assist organizations in determining compliance and developing processes to ensure compliance.
Foundations of Patient Safety
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Patient Safety Structural Measure Resource Guide
A guide organizations can use to review the goal of each domain, specific attestations that are expected to me made for compliance and applicable resources to that can be used to help either determine compliance or develop processes to meet the attestations. The resources provided are both LHATF and national resources. Live links are included to access the resources.
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Patient Safety Structural Measure Gap Analysis
A gap analysis for the organization to complete to determine opportunities for improvement for the PSSM. The development of this document was a collaborative effort between LHATF, LHA, and Louisiana hospitals that will be impacted by these measures. Links are provided within the document to access resources that may be helpful for performance improvement.
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IHI-NSC Implementation Resource Guide
A companion document to the Safer Together: A National Action Plan to Advance Patient Safety. The implementation guide is an overview of the aims, recommendations, and suggested tactics for implementing the recommendations for each of the foundational areas of the National Action Plan; and carefully curated organizational case examples, selected resources, and additional reading to support implementation efforts.
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Safer Together: A National Action Plan to Advance Patient Safety
This National Action Plan was developed from knowledge of the National Steering Council for Patient Safety (NSC) to illuminate collective insights on patient safety improvement. Patient Safety Structural Measure arises from the information in this document.
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Self Assessment Tool: A National Action Plan to Advance Patient Safety
This self-assessment tool is a companion to the Safer Together paper and the Implementation Resource Guide. The tool is separated into four foundational areas and is intended for healthcare delivery organizations to use for learning and to track progress over time.
Domain 1: Leadership Commitment to Eliminating Preventable Harm
The senior leadership and governing board at hospitals sets the tone for commitment to patient safety. They must be accountable for patient safety outcomes and ensure that patient safety is the highest priority for the hospital. While the hospital leadership and the governing board may convene a board committee dedicated to patient safety, the most senior governing board must oversee all safety activities and hold the organizational leadership accountable for outcomes. Patient safety should be central to all strategic, financial, and operational decisions.
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Framework for Effective Board Governance of Health System Quality
The evolution and expansion of healthcare over the years has warranted the need for Boards to allot more time and attention to the oversight of quality. This framework, developed by IHI, provides a framework of board governance, an assessment tool for Boards to evaluate the current state of oversight of the quality process and supportive guidance toward improvement.
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Sentinel Event Alert Issue 57: Culture, Safety, and Leadership
A great document to educate Board members. This Sentinel Event Alert was originally published in 2017 but was revised and republished in 2021. It addresses the role of leadership in the culture of safety and provides steps that can be implemented to achieve leadership engagement.
Doman 2: Strategic Planning and Organizational Policy
Hospitals must leverage strategic planning and organizational policies to demonstrate a commitment to safety as a core value. The use of written policies and protocols that demonstrate patient safety is a priority, and identifying goals, metrics and practices to advance progress is foundational to creating an accountable and transparent organization. Hospitals should acknowledge the ultimate goal of zero preventable harm, even while recognizing that this goal may not be currently attainable and requires a continual process of improvement and commitment. Patient safety and equity in care are inextricable and therefore equity, with the goal of safety for all individuals, must be embedded in safety planning, goal-setting, policy and processes.
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Zero Harm: Striving to Reduce Preventable Harms - Point, Counterpoint, and Areas of Agreement
An article from PS Net, that discusses the scientific research surrounding zero harm and the barriers to achievement. The commentary includes a debate on the feasibility of zero harm as a goal.
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Actionable Evidence-Based Practices
The Patient Safety Movement is an organization committed to zero harm by disseminating actionable evidence-based practices that organizations can implement. They provide blueprints with step-by-step guidance on numerous conditions in patient care.
Domain 3: Culture of Safety & Learning Health System
Hospitals must integrate a suite of evidence-based practices and protocols that are fundamental to cultivating a hospital culture that prioritizes safety and establishes a learning system both within and across hospitals. These practices focus on actively seeking and harnessing information to develop a proactive, hospital-wide approach to optimizing safety and eliminating preventable harm. Hospitals must establish an integrated infrastructure (i.e., people and systems working collaboratively) and foster psychological safety among staff to effectively and reliably implement these practices.
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How Leaders Can Build Psychological Safety at Work
An article from Center for Creative Leadership that 8 steps leaders can take to build greater psychological safety in the workplace.
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Safety Strategies Every Nurse Leader Needs to Know
An article from American Nurses Association that discusses safety protocols that are of the utmost importance to the culture of safety.
Domain 4: Accountability & Transparency
Accountability for outcomes, as well as transparency around safety events and performance, represents the cornerstones of a culture of safety. For hospital leaders, clinical and non-clinical staff, patients, and families to learn from safety events and prevent harm, there must exist a culture that promotes event reporting without fear or hesitation, and safety data collection and analysis with the free flow of information.
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New Analysis Shows Hospitals Improving Performance on Key Patient Safety Measures Surpassing Pre-Pandemic Levels
An article published by the American Hospital Association shows hospital improvements on key patient safety and quality measures since the COVID-19 pandemic.
Domain 5: Patient and Family Engagement
The effective and equitable engagement of patients, families, and caregivers is essential to safer, better care. Hospitals must embed patients, families, and caregivers as co-producers of safety and health through meaningful involvement in safety activities, quality improvement, and oversight.
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The ONC Patient Engagement Playbook
A Playbook from the Office of the National Coordinator is an evolving resource for clinicians, practice staff, hospital staff, and other innovators: a compilation of tips and best practices collected from clinicians and health systems.
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Working with Patient and Families as Advisors: Implementation Handbook
Patient and family advisors are valuable partners in efforts to reduce medical errors and improve the safety and quality of health care. This handbook will assist you in using patients and family input to improve processes.