{"id":1085,"date":"2025-06-16T06:38:56","date_gmt":"2025-06-15T23:38:56","guid":{"rendered":"https:\/\/www.rldatix.com\/en-nam\/rldatix-supports-readiness-implementation-patient-safety-structure-measure\/"},"modified":"2026-04-07T20:14:41","modified_gmt":"2026-04-07T13:14:41","slug":"rldatix-supports-readiness-implementation-patient-safety-structure-measure","status":"publish","type":"post","link":"https:\/\/www.rldatix.com\/en-nam\/resources\/rldatix-supports-readiness-implementation-patient-safety-structure-measure\/","title":{"rendered":"How RLDatix supports readiness and implementation of CMS Patient Safety Structure Measure"},"content":{"rendered":"\n<p>The Centers for Medicare &amp; Medicaid Services (CMS) officially published the <a href=\"https:\/\/www.federalregister.gov\/documents\/2024\/08\/28\/2024-17021\/medicare-and-medicaid-programs-and-the-childrens-health-insurance-program-hospital-inpatient\">final rule<\/a> for the Patient Safety Structural Measure (PSSM) in 2024. The ruling underscored the importance of leveraging connected data to proactively prevent harm, foster a culture of transparency and continuous improvement and ensure ongoing compliance with regulatory expectations.<\/p>\n\n\n\n<p>This measure will require hospitals to attest to whether they have implemented a culture of safety aligning to the PSSM\u2019s five domains. Hospitals will be scored from zero to five, with one point awarded per domain:&nbsp;<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Leadership commitment to eliminating preventable harm<\/li>\n\n\n\n<li>Strategic planning and organizational policy<\/li>\n\n\n\n<li>Culture of safety and learning health systems<\/li>\n\n\n\n<li>Accountability and transparency<\/li>\n\n\n\n<li>Patient and family engagement&nbsp;<\/li>\n<\/ol>\n\n\n\n<p>Patient safety is a journey \u2014 and this latest CMS measure is another opportunity for healthcare leaders to assess readiness and learn how their organization can connect actionable data and operations to take action and deliver safer care. With 25+ years in patient safety advocacy, and having served as an architect for the Agency for Healthcare Research and Quality\u2019s (AHRQ) CANDOR toolkit, I\u2019m pleased to help hospitals and healthcare systems further improve the quality of the patient care that they deliver.&nbsp;<\/p>\n\n\n\n<p>In this post, domain by domain, I\u2019ll summarize:&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>The domain\u2019s focus<\/li>\n\n\n\n<li>The domain\u2019s&nbsp;key requirements<\/li>\n\n\n\n<li>The&nbsp;RLDatix solutions that can help you positively attest to the domain<\/li>\n<\/ul>\n\n\n\n<p><strong>Domain 1: Leadership commitment to eliminating preventable harm&nbsp;<\/strong><\/p>\n\n\n\n<p>Domain 1 focuses on the hospital\u2019s senior leadership and governing board\u2019s actions in making its commitment to patient safety its highest priority. It directs the governing board to oversee all safety activities and to hold leadership accountable for patient safety outcomes. All strategic, financial and operational decisions should have patient safety at their core.&nbsp;<\/p>\n\n\n\n<p><strong>PSSM Domain 1 key requirements<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patient safety metrics that inform annual leadership performance reviews and compensation.<\/li>\n\n\n\n<li>System-wide assessment on safety and patient safety initiatives and operations with improvement plans and metrics, shared across the hospital and governing board.<\/li>\n\n\n\n<li>Sufficient&nbsp;patient safety resources (such as equipment, training, systems, personnel and technology).<\/li>\n\n\n\n<li>Reporting on patient and workforce safety events and initiatives&nbsp;that account for at least 20% of the regular board agenda and senior governing board meeting discussion time.<\/li>\n\n\n\n<li>C-Suite and the senior governing board are notified within three business days of safety events resulting in significant morbidity, mortality or other harm.<\/li>\n<\/ul>\n\n\n\n<p><strong>How RLDatix can help you positively attest to PSSM Domain 1<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/event-reporting\/\">Event Reporting<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/credentialing-privileging\/\">Credentialing and Privileging<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/root-cause-analysis\/\">Root Cause Analysis<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/risk-register\/\">Risk Register<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/peer-review\/\">Peer Review<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/audits-standards\/\">Audits &amp; Standards<\/a><\/li>\n\n\n\n<li>Workforce Management<\/li>\n<\/ul>\n\n\n\n<p><strong>Domain 2: Strategic planning and organizational policy&nbsp;<\/strong><\/p>\n\n\n\n<p>Domain 2 focuses on committing to safety as a core value, by documenting policies and protocols, and identifying goals, metrics and practices, to create accountability and transparency across the organization. It instructs hospitals to strive for, whether attainable or not, zero preventable harm, which requires continuous process improvement. Equity in care should be embedded in safety planning, goal-setting, policy and processes.<\/p>\n\n\n\n<p><strong>PSSM Domain 2 key requirements<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Strategic plan that outlines specific safety goals and associated metrics, with the goal of zero preventable harm.<\/li>\n\n\n\n<li>Safety goals&nbsp;that use&nbsp;metrics,&nbsp;most relevant to the patient characteristics of the populations served,&nbsp;to&nbsp;identify&nbsp;and address disparities in safety outcomes.<\/li>\n\n\n\n<li>Implementation of&nbsp;written policies and protocols&nbsp;that&nbsp;cultivate a just culture,&nbsp;balancing&nbsp;no-blame and&nbsp;appropriate accountability.<\/li>\n\n\n\n<li>Implementation of a patient safety curriculum and competencies, with regular assessments,&nbsp;for all clinical and non-clinical hospital staff.<\/li>\n\n\n\n<li>Action plan&nbsp;that includes improvement activities,&nbsp;metrics&nbsp;and trends&nbsp;for workforce safety.<\/li>\n<\/ul>\n\n\n\n<p><strong>How&nbsp;RLDatix&nbsp;can help you positively attest to PSSM Domain 2<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/event-reporting\/\">Event Reporting<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/root-cause-analysis\/\">Root Cause Analysis<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/credentialing-privileging\/\">Credentialing and<\/a><a href=\"https:\/\/rldatix.com\/en-nam\/solutions\/how-we-help\/governance\/provider-credentialing-and-privileging\/\"> Privileging<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/peer-review\/\">Peer Review<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/peer-support\/\">Peer Support<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/policy-management\/\">Policy Management<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/audits-standards\/\">Audits &amp; Standards<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/platform\/workforce-operations\/\">Workforce Management<\/a>&nbsp;<\/li>\n<\/ul>\n\n\n\n<p><strong>Domain 3: Culture of safety&nbsp;and&nbsp;learning health systems&nbsp;<\/strong><\/p>\n\n\n\n<p>Domain 3 focuses on integrating&nbsp;evidence-based practices&nbsp;and&nbsp;protocols&nbsp;hospital-wide, with people and systems working collaboratively,&nbsp;to prioritize safety and&nbsp;establish&nbsp;a learning system. It directs hospitals to&nbsp;seek information continuously to take a proactive approach to&nbsp;eliminating&nbsp;preventable harm. Integration of people and systems requires fostering psychological safety among staff.&nbsp;<\/p>\n\n\n\n<p><strong>PSSM Domain 3 key requirements<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Hospital-wide culture of safety survey annually, or every&nbsp;two&nbsp;years with pulse surveys during non-survey years, with results&nbsp;shared with the governing board and hospital staff.<\/li>\n\n\n\n<li>Dedicated team that conducts&nbsp;evidence-based&nbsp;event analysis of serious safety events.<\/li>\n\n\n\n<li>Patient safety metrics dashboard&nbsp;that also&nbsp;includes&nbsp;external benchmarks.<\/li>\n\n\n\n<li>Implementation of&nbsp;specific&nbsp;high reliability practices&nbsp;for improving safety culture and learning systems.<\/li>\n\n\n\n<li>Participation&nbsp;in large-scale learning network(s) for patient safety improvement, share data on safety events and outcomes with these network(s)&nbsp;and&nbsp;implement at least one&nbsp;learned&nbsp;best practice.&nbsp;<\/li>\n<\/ul>\n\n\n\n<p><strong>How&nbsp;RLDatix&nbsp;can help you positively attest to PSSM Domain 3<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/company\/the-safety-institute\/\">Safety Institute<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/root-cause-analysis\/\">Root Cause Analysis<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/event-reporting\/\">Event Reporting<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/safety-huddles\/\">Safety Huddles<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/peer-support\/\">Peer Support<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/policy-management\/\">Policy Management<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/audits-standards\/\">Audits &amp; Standards<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/manufacturers-guidelines\/\">Manufacturer&#8217;s Guidelines<\/a><\/li>\n<\/ul>\n\n\n\n<p><strong>Domain 4: Accountability&nbsp;and&nbsp;transparency&nbsp;<\/strong><\/p>\n\n\n\n<p>Domain 4 focuses on the vitalness of accountability and transparency&nbsp;in&nbsp;building a culture of safety. It&nbsp;states&nbsp;that learning from safety events and preventing harm, through data collection and analysis,&nbsp;are&nbsp;possible&nbsp;only&nbsp;when hospitals promote event reporting without fear and hesitation.&nbsp;<\/p>\n\n\n\n<p><strong>PSSM Domain 4 key requirements<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Confidential safety reporting system that allows staff to report patient safety events, near misses, precursor events, unsafe conditions and other concerns, and prompts a feedback loop to those who report.<\/li>\n\n\n\n<li>Reporting&nbsp;serious safety events, near misses and precursor events to a PSO listed by the&nbsp;AHRQ.<\/li>\n\n\n\n<li>Tracking and reporting patient safety metrics to all clinical and non-clinical staff&nbsp;publicly.<\/li>\n\n\n\n<li>Defined, evidence-based communication and resolution program reliably implemented after harm events.<\/li>\n\n\n\n<li>Tracking&nbsp;and reporting&nbsp;communication and resolution program&nbsp;performance with standard measures&nbsp;to the governing board at least quarterly.&nbsp;<\/li>\n<\/ul>\n\n\n\n<p><strong>How&nbsp;RLDatix&nbsp;can help you positively attest to PSSM Domain 4<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/company\/the-safety-institute\/\">Safety Institute<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/event-reporting\/\">Event Reporting<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/root-cause-analysis\/\">Root Cause Analysis<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/risk-register\/\">Risk Register<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/claims\/\">Claims Management<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/peer-support\/\">Peer Support<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/feedback\/\">Feedback<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/platform\/workforce-operations\/\">Workforce Management<\/a>&nbsp;<\/li>\n<\/ul>\n\n\n\n<p><strong>Domain 5: Patient&nbsp;and&nbsp;family engagement&nbsp;<\/strong><\/p>\n\n\n\n<p>Domain 5 focuses on&nbsp;delivering safer, better care through&nbsp;hospital&nbsp;engagement&nbsp;with&nbsp;patients, families and caregivers.&nbsp;It instructs hospitals to involve these groups in safety activities, quality improvement and oversight.&nbsp;<\/p>\n\n\n\n<p><strong>PSSM Domain 5 key requirements<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patient and Family Advisory Council that ensures patient, family, caregiver and community input to safety-related activities, including representation at board meetings, consultation on safety&nbsp;goal-setting&nbsp;and metrics and participation in safety improvement initiatives.<\/li>\n\n\n\n<li>Patient and Family Advisory Council that is diverse&nbsp;and&nbsp;representative&nbsp;of the patient population.<\/li>\n\n\n\n<li>Incorporating&nbsp;patient and caregiver input about patient safety events or issues.<\/li>\n\n\n\n<li>Supporting&nbsp;the presence of family and other designated persons as essential members of a safe care team and encourages engagement.<\/li>\n<\/ul>\n\n\n\n<p><strong>How&nbsp;RLDatix&nbsp;can help you positively attest to PSSM Domain 5<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/rldatix.com\/en-nam\/solutions\/how-we-help\/risk\/event-reporting\/\">Event R<\/a><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/event-reporting\/\">eporti<\/a><a href=\"https:\/\/rldatix.com\/en-nam\/solutions\/how-we-help\/risk\/event-reporting\/\">ng<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/product\/root-cause-analysis\/\">Root Cause Analysis<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/safety-huddles\/\">Safety Huddles<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/claims\/\">Claims&nbsp;Management<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.rldatix.com\/en-nam\/module\/feedback\/\">Feedback<\/a>&nbsp;<\/li>\n<\/ul>\n\n\n\n<p><strong>Assess&nbsp;your&nbsp;readiness for CMS Patient Safety Structural Measure&nbsp;<\/strong><\/p>\n\n\n\n<p>Patient safety is a&nbsp;journey.&nbsp;<\/p>\n\n\n\n<p>The CMS Patient Safety Structural Measure is&nbsp;a terrific roadmap for us, as&nbsp;healthcare leaders,&nbsp;to&nbsp;follow in our pursuit&nbsp;of zero preventable harm.&nbsp;<\/p>\n\n\n\n<p>We can do this by&nbsp;continuously&nbsp;learning,&nbsp;improving&nbsp;and&nbsp;exploring&nbsp;how we&nbsp;connect data and operations&nbsp;to deliver&nbsp;safer, better care for our patients.&nbsp;<\/p>\n\n\n\n<p>To&nbsp;learn more about&nbsp;how&nbsp;RLDatix&nbsp;can&nbsp;help&nbsp;assess&nbsp;readiness&nbsp;and implementation of&nbsp;the&nbsp;CMS Patient Safety Structural Measure,&nbsp;<a href=\"https:\/\/www.rldatix.com\/en-nam\/book-a-demo\/\">connect with one of our&nbsp;experts<\/a>.&nbsp;<\/p>\n\n\n\n<p><em><strong>Tim McDonald, MD,&nbsp;JD, is the Chief Patient Safety and Risk Officer at&nbsp;RLDatix&nbsp;and a Professor of Law at Loyola University, Chicago. He is a Harvard-trained anesthesiologist, pediatrician, licensed attorney, patient safety\/medical liability specialist and author&nbsp;of&nbsp;articles in renowned&nbsp;peer-reviewed&nbsp;journals.&nbsp;His&nbsp;expertise&nbsp;has been recognized nationally and internationally, including authorship of references for the President\u2019s Council of Advisors on Science and Technology Patient Safety Report.&nbsp;<\/strong><\/em><\/p>\n\n\n\n<p><em><strong>Known for his TED x San Diego Talk,&nbsp;Tim is passionate about&nbsp;working with patients,&nbsp;families&nbsp;and&nbsp;healthcare&nbsp;providers,&nbsp;to&nbsp;shatter the wall of silence,&nbsp;by sharing stories and fostering&nbsp;a culture of compassionate honesty, fair&nbsp;accountability&nbsp;and patient safety transformation.<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Learn how RLDatix solutions can support your healthcare organization to positively attest to the CMS Patient Safety Structure Measure five domains.<\/p>\n","protected":false},"author":16,"featured_media":1086,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"categories":[34],"tags":[],"class_list":["post-1085","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-blog","primary-category-blog"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>How RLDatix Supports Readiness and Implementation of CMS Patient Safety Structure Measure<\/title>\n<meta name=\"description\" content=\"Learn how RLDatix solutions can support your healthcare organization to positively attest to the CMS Patient Safety Structure Measure five domains.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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