Centers for Medicare and Medicaid Services (CMS) Patient Safety Structural Measure: An Overview for Anesthesia Professionals

THE PATIENT SAFETY STRUCTURE MEASURE

Patient harm continues to occur in hospitalized patients, with at least one adverse event occurring in almost 24% of admissions.¹ Recognizing this, the Centers for Medicare & Medicaid Services (CMS) announced the Patient Safety Structural Measure (PSSM) for acute care hospitals.^1-3 Beginning in Spring 2026, acute care hospitals participating in the Hospital Inpatient Quality Reporting (IQR) and Prospective Payment System Exempt Cancer Hospital Quality Reporting (PCHQR) programs will self-attest to their performance on structural and cultural safety practices for the 2025 calendar year. Hospital scores will be public on the CMS Care Compare website in October 2026 and the reporting incentive will be reflected in hospitals’ fiscal year 2027 payment determinations from CMS. Hospitals will face a decrease in their annual Medicare reimbursement if they fail to report on the PSSM.

The PSSM requires applicable hospitals to attest to their engagement in specific, evidence-based practices for five domains that are deemed essential for system safety, including 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. Attestation to each of the practices within a domain is required for the hospital to receive a point for the domain.³ We discuss the evidence-based practices in each of the domains, as well as the role of anesthesia professionals in assisting hospitals with the achievement of these practices.

WHY IS A PATIENT SAFETY STRUCTURAL MEASURE NECESSARY?

While outcome measures reflect the results of care, the domains and elements of the PSSM reflect the most salient, evidence-based, structural and cultural elements of safety, and assess the features of a hospital relevant to its ability to provide safe care, such as leadership practices and operational policies and processes that support patient safety. This attestation-based measure requires applicable hospitals to assess and report the degree to which they meet elements across each of the domains. A summary of key elements in each domain can be found in Table 1. The domains and elements of the PSSM are aligned with the Safer Together: A National Action Plan to Advance Patient Safety, the CMS National Quality Strategy and Health Equity Structural Measure, the Health and Human Services National Action Alliance for Patient and Workforce Safety, and much of the focus of the World Health Organization Global Patient Safety Action Plan. Additional information on the PSSM, including an Attestation Guide, may be found on the CMS website (https://qualitynet.cms.gov/inpatient/iqr/measures#tab2).

Table 1. Sample of key elements that hospitals must attest to in each of the Patient Safety and Structural Measure (PSSM) Domains.

PSSM Domain	Key Elements That Hospitals Must Attest to in Domain
1. Leadership Commitment to Eliminating Preventable Harm
The hospital leadership and governance board must establish the organization’s commitment to patient safety.	Safety must be prioritized as a core value and hospital leadership is held accountable for patient safety by ensuring adequate resources are available to support safety programs. Safety events and initiatives must be discussed regularly at board meetings, and serious safety events must be discussed by the board within three days of their occurrence.
2. Strategic Planning and Organizational Policy
This domain addresses the importance of an organization’s commitment to a goal of zero preventable harm, to foster the mindset that preventable harm is unacceptable.	Hospitals must have a public strategic plan that shares their commitment to patient safety and utilizes metrics to identify and address disparities in safety outcomes. A patient safety curriculum and competencies must be developed for all clinical and nonclinical staff, and an action plan to address safety, including activities which cultivate a just culture, will be developed.
3. Culture of Safety and Learning Health Systems
A culture of learning and a proactive approach to achieving safety is essential to reducing harm.	Hospitals must conduct regular culture of safety surveys and have a dedicated team that conducts event analysis using an evidence-based approach. Hospitals must use a safety metrics dashboard with external benchmarks to monitor performance, must participate in a large-scale learning network, and must implement high reliability practices.
4. Accountability and Transparency
Accountability to patients and the workforce is critical and requires transparency around adverse events and performance.	Hospitals will use a confidential safety reporting system and work with a Patient Safety Organization listed by the Agency for Healthcare Research and Quality to carry out patient safety activities. Patient safety metrics will be tracked and made publicly visible on hospital units. An evidence-based communication and resolution program (CRP) that is implemented after harm events will be established, and the performance of the program will be presented regularly to the hospital board.
5. Patient and Family Engagement
This domain addresses the importance of meaningfully embedding patients, families, and caregivers in co-producing safety for themselves and for the organization.	Hospitals must have a diverse patient and family advisory council (PFAC) that is representative of the patient population and provides input on safety-related activities. Patients will have comprehensive access to their medical records, and the presence of persons designated by the patients as essential members of their care team must be supported by the hospital.

ANESTHESIA PROFESSIONALS’ ROLE IN WORKING WITH HOSPITALS TO ACHIEVE THE PSSM DOMAINS

Safety is an important component of education in the training of anesthesia professionals.⁴ Given the historic and ongoing role that anesthesia professionals play in leading patient safety initiatives and serving in patient safety leadership roles, we are well-suited to teach essential components of patient safety within a health system.⁵ Frameworks for educating clinicians and nonclinicians in patient safety can be adapted from several sources. The American Society of Anesthesiologists’ Fundamentals of Patient Safety Educational program is revised regularly with updated content and addresses the epidemiology of safety, culture, communication, analysis and prevention of adverse events, and strategies for implementing and continuously improving reliable systems. The Institute for Healthcare Improvement’s Certified Professional in Patient Safety (CPPS) Review Course covers key domains based upon a job analysis of practicing patient safety professionals, which currently include the following: culture; systems thinking, human factors engineering, and design; safety risks and responses; and performance measurement, analysis, improvement, and monitoring.⁶ While the content and emphasis of the CPPS domains in the Patient Safety Structural Measure’s required education of all clinical and nonclinical staff must be adapted for various audiences, these domains represent core content areas of safety science and practice, with availability of continuing medical education credit. The use of the CPPS domains as a framework could benefit interested and eligible candidates who wish to seek certification.

With increasing focus on perioperative outcomes and recognition of anesthesiology as a bridge between medical and surgical specialties, anesthesia professionals are well-suited to advise hospital boards on safety assessment and initiatives as well as identify resources necessary to bring these initiatives to fruition.^7,8 While improvement projects for safety often address clinical variation, whole system safety requires balanced attention to strategic and operational variation which has been a key target of anesthesia professionals and is the current focus of the Patient Safety Structural Measure.⁹ For example, anesthesia professionals can reference the work of the American Society of Anesthesiologists Statement on Safety Culture (https://www.asahq.org/standards-and-practice-parameters/statement-on-safety-culture) and the work of the Anesthesia Patient Safety Foundation’s Patient Safety Priorities Advisory Groups (https://www.apsf.org/patient-safety-priorities/) when advising their hospital leadership on best practices to improve patient safety. In addition to these resources, the National Steering Committee for Patient Safety has developed an action plan for organizations, as well as a self-assessment tool and implementation resource guide, which can be accessed from the Institute for Healthcare Improvement website. (https://www.ihi.org/national-action-plan-advance-patient-safety)

CONCLUSION

Transformational progress is necessary to improve safety for our patients and the workforce. It will not be achieved by treating safety as a clinical improvement project focusing on a narrow safety challenge, nor will it be achieved by treating safety as a priority, as priorities are subject to change. Patient safety will be achieved by targeting the system and treating it as a purpose, a nonnegotiable true north among other organizational priorities.¹⁰ Due to their broad education and training in safety, anesthesia professionals are invaluable assets for a health care organization as it executes systems-oriented actions to advance safety and attests to the PSSM practices. Most of the elements within the PSSM domains are routine practices used by anesthesia professionals and are ubiquitous for safety in all settings. By working with the hospital leaders, anesthesia professionals can demonstrate that their value extends well beyond the operating rooms, procedural areas, and ICUs and can benefit the entire organization.

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