When the Sarbanes–Oxley Act of 2002 was passed, it required C-level corporate leaders to make attestations about the accuracy of their company’s financial filings. The question leaders had at the time was, how can we know they are correct? Do we have the systems to confidently make these attestations? Healthcare leaders now face this same question for the Patient Safety Structural Measure (PSSM).
The spotlight is on patient safety, since one in four Medicare patients are still being harmed. Regulators intend the PSSM to assess how well hospitals have implemented strategies and practices to strengthen their systems and culture for safety. PSSM requires a set of attestations that affirm hospitals have systems in place that advance safety. The regulation requires five specific attestations in each of five domains, which must be answered yes or no. What is your organizational readiness for this new regulation?
Challenges of the Patient Safety Structural Measure
Some people are describing the PSSM as overwhelming. Today, hospitals can likely meet some of the activities for some domains, but this will result in lower CMS PSSM scores than desired. On a recent IHI webinar, less than half of hospitals responded that they can confidently obtain a high score. For hospital executives to confidently make the attestations in the affirmative, they will need an effective data infrastructure to measure and report on patient safety. This infrastructure needs:
- The ability to efficiently collect safety data
- Tools for safety data analysis
- Methods for sharing the information with relevant stakeholders and leaders
These are part of a complete and robust quality management system (QMS). The table below shows the key data capabilities extracted from the PSSM and the QMS implications for making a positive statement.
| PSSM Requirement | QMS Implication |
| Patient safety metrics are shared across the hospital and with leadership | System to collect safety data Method for widely sharing data |
| The board must review patent and workforce safety data | An efficient way of presenting data in a form that is easily understood by the board |
| C-suite and the board must be notified quickly when there is a serious safety event | Automation of event notifications is the most straightforward way to accomplish this |
| Safety goals must use metrics related to disparities in specific populations. | Begin collecting SDOH data and connecting it to safety metrics |
| Plan for workplace safety with metrics. | Easy method like a web form for staff event reporting |
| Culture of Safety Survey | Efficient tools for gathering survey responses and reporting on them |
| Safety dashboard with external benchmarks data | Ability to create relevant dashboards Ability to distribute the dashboards A source of external benchmark data |
| Confidential safety reporting system | Easy method like a web form for staff event reporting that allows for anonymity |
| Reporting to a PSO | Efficiently gather safety data and package it for the PSO |
| Track performance of standard measures | A tool for consistent tracking and trending the measures |
Key elements of a patient safety solution
For your executives to have confidence in making the patient safety attestations, you will need a quality management system that provides specific capabilities:
- Custom data collection
- Ability to synthesize data from multiple sources
- Ways to track and trend data over time and perform statistical analysis
- Tools for collaboration and reporting
- Worklists to assure processes are followed
- Easy event sharing and distribution
- Survey tools
- Dashboard and reporting tools
It is also helpful if your software partners have a strong regulatory program to give you peace of mind that indicators are up to date.
The PSSM is intended to be consistent with a culture of safety. Confidently making positive attestations leading to high scores requires an effective data infrastructure.
