CMS May Introduce New Patient Safety Measure
EXECUTIVE SUMMARY
Centers for Medicare & Medicaid Services is considering a new patient safety quality measure. It would assess how well hospitals adopt strategies shown to improve safety.
- Hospitals must affirm compliance with five domains.
- The maximum number of points is five.
- The measure would begin with the calendar year 2025 reporting period.
By Greg Freeman
Centers for Medicare & Medicaid Services (CMS) is considering a new quality measure aimed at assessing hospitals’ success with implementing patient safety strategies. The proposed fiscal year (FY) 2025 Hospital Inpatient Prospective Payment System (PPS) rule includes a CMS proposal to adopt the Patient Safety Structural Measure (PSSM) for the Hospital Inpatient Quality Reporting (IQR) Program and the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program beginning with the calendar year 2025 reporting period. That would be for the FY 2027 payment determination.
More information on the measure is available online at https://go.cms.gov/3T8HXt4.
The PSSM was developed by a Technical Expert Panel, which was comprised of safety experts, including Tejal Gandhi, MPH, CPPS, chief safety and transformation officer with Press Ganey in Fort Worth, TX.
Gandhi explains that the PSSM is an attestation-based measure with five domains, each containing multiple statements aimed at capturing the most important structural and cultural elements of patient safety. These are the domains:
- Leadership commitment to eliminating preventable harm
- Strategic planning and organizational policy
- Culture of safety and learning health systems
- Accountability and transparency
- Patient and family engagement
Hospitals must show affirmative attestation to all statements within a domain to receive a point for the domain, Gandhi says. There is one point per domain, so hospitals can earn a maximum of five points for the measure. CMS plans to publicly report performance scores annually on Care Compare starting in fall 2026, she says.
“CMS has been trying to incentivize organizations to do more work in patient safety, and the way that they’ve done it has been through the hospital-acquired conditions and having penalties for organizations that maybe have worse performance on outcomes, and outcomes like readmissions or infections,” Gandhi says. “I think the leadership at CMS really realized that, yes, we can kind of do this work related to outcomes, but really what we want organizations to do is to do this foundational work that will help them improve across the board and ultimately impact those outcomes.”
There has been some controversy about the effectiveness of attestation measures because organizations only have to say yes or no to each item, but Gandhi says the move still can be effective.
“I think it puts a stake in the ground of what CMS expect organizations to be doing. It’s an important exercise for organizations to walk through the measure and really think about what they are doing effectively and what are they not,” she says. “It’s a very good starting point to sort of push organizations to do this upstream work.”
Source
- Tejal Gandhi, MPH, CPPS, Chief Safety and Transformation Officer, Press Ganey, Fort Worth, TX. Email: [email protected].
Centers for Medicare & Medicaid Services is considering a new quality measure aimed at assessing hospitals’ success with implementing patient safety strategies.
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